Three-Year Survival of Critical Limb-Threatening Ischemia Patients With FFRCT-Guided Coronary Revascularization Following Lower-Extremity Revascularization

Objective. The study objective is to determine whether selective coronary revascularization following lower-extremity revascu-larization can improve long-term survival of patients with critical limb threatening ischemia (CLTI). Methods. This study compared CLTI patients with no cardiac history or symptoms who underwent limb-salvage surgery. Group I comprised 103 patients with preoperative coronary computed-tomography derived fractional flow reserve (FFR_CT) used to detect ischemia-producing coronary stenosis (FFR_CT ≤0.80) with selective postoperative coronary revascularization (the FFR_CT-guided group) and group II comprised 120 patients with standard preoperative evaluation and no postoperative coronary revascularization (the standard-care group). Both groups received guideline-directed medical therapy. Study endpoints were all-cause death, cardiovascular (CV) death, and myocardial infarction (MI) during 3-year follow-up. Results. Preoperative evaluation in the FFR_CT-guided group revealed unsuspected (silent) coronary ischemia in 2 of 3 patients (69%) with left main coronary ischemia in 8%. Elective coronary revascular-ization was performed in 47 patients (46%) 1-3 months following limb-salvage surgery. Standard-care patients had no coronary revascularization. During median follow-up of 36 months, the FFR_CT-guided group had fewer deaths (10.7% vs 27.5%; hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.16-0.64; P<.01); fewer CV deaths (2.9% vs 17.5%; HR, 0.14; 95% CI, 0.04-0.48; P<.01); and fewer MIs (3.9% vs 22.5%; HR, 0.14; 95% CI, 0.05-0.40; P<.01) compared with the standard-care group. Conclusions. FFR_CT evaluation of CLTI patients with no coronary symptoms revealed a high prevalence of unsuspected (silent) coronary ischemia. Coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization reduced CV deaths and MIs and improved 3-year survival (89%) compared with standard cardiac evaluation and care (73%).