Circ Rep. 2026 Apr 11;8(6):980-987. doi: 10.1253/circrep.CR-26-0063. eCollection 2026 Jun 10.
ABSTRACT
BACKGROUND: Below-the-ankle (BTA) disease is increasingly prevalent in chronic limb-threatening ischemia (CLTI), particularly in diabetes and end-stage renal disease, but its determinants and prognostic impact after revascularization remain unclear.
METHODS AND RESULTS: We retrospectively analyzed 185 CLTI limbs with complete pedal angiography undergoing revascularization at 2 vascular centers between 2002 and 2023. Using the Global Limb Anatomic Staging System (GLASS) inframalleolar/pedal artery descriptor (IPD), limbs were classified as BTA (IPD-P2; n=40) or nonBTA (IPD-P0 or P1; n=145). Logistic regression identified factors associated with BTA. Kaplan-Meier compared limb-based patency (LBP), wound healing, limb salvage, and survival. BTA limbs presented with more severe limb status (WIfI stage 4: 72.5% vs. 41.0%; P=0.001), whereas GLASS stage was similar. On multivariable analysis, nonambulatory status independently predicted BTA disease (adjusted odds ratio 2.65; 95% confidence interval 1.19-5.94; P=0.02). BTA disease was associated with lower 1year primary/secondary LBP (55.6% and 72.4% vs. 75.2% and 86.1%; P=0.004 and P=0.005), 6month wound healing (54.0% vs. 83.2%; P=0.0002), 1year limb salvage (77.3% vs. 97.2%; P<0.0001), and 1year survival rates (67.9% vs. 85.6%; P=0.003).
CONCLUSIONS: Non-ambulatory status was independently associated with advanced BTA disease. Despite similar GLASS stage, BTA involvement predicted worse patency, limb outcomes, and survival, suggesting pedal arterial status reflects systemic disease severity.
PMID:42273313 | PMC:PMC13249483 | DOI:10.1253/circrep.CR-26-0063