The Influence of Connective Tissue Disease in the Management of Lower Limb Ischemia

Introduction: Vascular intervention for patients with connective tissue disease (CTD) and symptomatic limbs, particularly with tissue loss, is associated with poor outcomes. The aims of our study were to compare outcomes from arterial interventions for patients with CTD versus overall results for our unit and analyse available baseline patient characteristics to determine whether any features were associated with poor prognosis. Methods: We retrieved data from a prospectively maintained database of all patients undergoing interventions on the vascular unit since 1984. The database included coding for CTD and tissue loss at presentation. Information was retrieved for each patient with CTD identified for a period of 2 years postoperatively. Additional data were retrieved from patient's notes. Results: CTD was identified in 23 patients, 12 men and 11 women, with a median age of 68 years (range 42-84). The majority of patients suffered from rheumatoid arthritis. Of 13 patients who presented with peripheral arterial disease (PAD) and associated tissue loss, 12 underwent arterial procedures, and 1 had a primary amputation. Of 5 endovascular procedures performed, 4 failed, 2 immediately and 2 subsequently. Seven patients had major amputations at 6 months. At 2 years, 11 of 13 patients (84.6%) had major amputations, and of the remaining 2, 1 had persisting ulceration. In comparison, of the 10 patients presenting with critical limb ischemia without tissue loss, there was 1 amputation, which occurred at 12 months, and 1 patient died, a limb loss/death rate at 24 months of 20%. A backward binary logistic regression analysis showed that neither gender nor age had a significant effect in predicting limb loss, but tissue loss at presentation was associated with a significantly higher rate of amputation. Conclusions: Patients with CTD and PAD who present with lower limb tissue loss appear to be at greater risk of limb loss after vascular intervention compared with the general vascular population managed by our unit. CTD patients with no tissue loss had outcomes comparable to the general vascular population. We suggest that the management of patients with CTD and PAD presenting with lower limb tissue loss should include focused, aggressive treatment of underlying inflammation and nutrition.