Impact of Nutrition on Outcomes of Limb Salvage For Chronic Limb-Threatening Ischemia

• Published in: Journal of vascular surgery
• Main Authors: Hart, Joseph P., Davies, Mark G.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 11.08.2025
• Subjects: Bypass; CLTI; Endovascular; immunocompetence; Nutrition; Outcomes; Prognostic nutritional index; CLTI; Nutrition; Bypass; Endovascular; Prognostic nutritional index; immunocompetence; Outcomes
• ISSN: 0741-5214; 1097-6809; 1097-6809
• DOI: 10.1016/j.jvs.2025.08.005

Poor nutrition and decreased immunocompetency are identified frequently among vascular patients and predict poor surgical outcomes. The intent of this study was to quantify the impact of varying degrees of malnutrition and immunocompetence on the outcomes of subjects undergoing lower extremity intervention for chronic limb-threatening ischemia (CLTI). Between 2018 and 2022, all patients undergoing a primary intervention for CLTI (bypass, BYP, or endovascular intervention, EV) were included. Nutritional state and immune-competency status was measured by use of the prognostic nutritional index (PNI 10 × serum albumin (g/dl) + 0.005 × total lymphocyte count (per mm3). Patients were designated as Normal (PNI value > 50), Mild malnutrition (PNI value 50-46), Moderate malnutrition (PNI value 45-40) and Severe malnutrition (PNI value< 40) for stratification. Amputation-free survival (AFS; survival without major amputation) and avoidance of major adverse limb events (MALE; Above ankle amputation of the index limb or major re-intervention (new bypass graft, jump/interposition graft revision) were evaluated. 1207 patients (64% male, aged 65±11years, mean ± SD) underwent either EV (66%) or BYP (34%). Of these patients, 17% were grouped as Normal, 25% as Mild, 34% as Moderate, and 24% as Severe. Increasing age and increasing Charlson comorbidity index were positively associated with increasing severity of the PNI. Increasing severity of PNI impacts 30-day MACE (3% vs. 3% vs. 10% vs. 15%, Normal vs. Mild vs. Moderate vs. Severe PNI; P=.002 compared to Normal PNI), 30-day MALE (4% vs. 7% vs. 11% vs. 19%) and 30-day amputation (3% vs. 5% vs. 7% vs. 11%; P=.001 compared to Normal PNI), Wound healing at 3 months decreased as PNI worsened (83% vs. 71% vs. 53% vs. 40%; P =.001 compared to Normal PNI). At five years, both freedom from MALE (63±5% vs. 54±4% vs. 38±5% vs. 23±4%; Mean ±SEM; P =.001 compared to Normal PNI) and Amputation-free Survival ( 59±5% vs. 45±6% vs. 36±5% vs. 25±4% P =.001 compared to Normal PNI) were significantly worse as PNI severity increased. More than 50% of patients who present with CLTI have evidence of poor nutrition and decreased immunocompetence as defined by the PNI. The increasing severity of PNI leads to poorer short-term and long-term outcomes. Identifying patients with poor nutrition and decreased immunocompetence may further stratify risks attributed to CLTI interventions. Type of Research: Single-center retrospective cohort studyKey Findings: 1207 patients undergoing a primary intervention for CLTI (endovascular intervention or bypass) were analyzed. Nutritional state and immune-competency status stratified by use of the prognostic nutritional index (PNI). In this cohort, 17% of the patients were categorized as Normal PNI, 25% as Mild PNI, 35% as Moderate PNI, and 24% as Severe PNI. Increasing age and increasing Charlson comorbidity index were positively associated with increasing severity of the PNI. Increasing severity of PNI impacts 30-day MACE, 30-day MALE and 30-day amputation. Wound healing at 3 months decreased as PNI worsened. At five years, both freedom from MALE and Amputation-free Survival were significantly worse as PNI severity increased.Take home Message: More than 50% of patients who present with CLTI have evidence of poor nutrition and decreased immunocompetence as defined by the PNI The increasing severity of PNI leads to poorer short-term and long-term outcomes.