LAUSR

OBJECTIVE Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers (ACEI/ARB) reduce the risk of cardiovascular events and mortality in patients with peripheral arterial disease (PAD). However, their effect on limb-specific outcomes is unclear. The objective of this study is to assess the effect of ACEI/ARB on patency and limb salvage in patients undergoing interventions for critical limb ischemia (CLI). METHODS Patients undergoing infrainguinal revascularization for CLI (Rutherford 4-6) between 06/2001-12/2014 were retrospectively identified. Primary Patency (PP), Secondary Patency (SP), Limb Salvage (LS), major adverse cardiac events (MACE) and survival rates were calculated using Kaplan-Meier. Multivariate analysis was performed using Cox regression. RESULTS A total of 755 limbs in 611 patients (311 ACEI/ARB, 300 No ACEI/ARB) were identified. Hypertension (86% vs 70%, P<.001), diabetes (68% vs 55%, P=.001) and statin use (61% vs 45%, P<.001) were significantly greater in the ACEI/ARB group. Interventions were performed mostly for tissue loss (83% ACEI/ARB vs 84% No ACEI/ARB, P= .73). Comparing ACEI/ARB vs No ACEI/ARB, in femoropopliteal interventions, 60-month PP (54% vs 55%, P=.47), SP (76% vs 75%, P=.83) and LS (84% vs 87%, P=.36) were not significantly different. In infrapopliteal interventions, 60-month PP (45% vs 46%, P=.66) and SP (62% vs 75%, P=.96) were not significantly different. LS was significantly greater in ACEI/ARB (75%) as compared to No ACEI/ARB (61%) (P= .005). Cox regression identified diabetes (HR 2.4 (1.4-4.1), P=.002), ESRD (HR 3.5 (2.1-5.7), P<.001), hypertension (HR 0.4 (0.2-0.6), P<.001) and ACEI/ARB (HR 0.6 (0.4-0.9), P=.03) as factors independently associated with LS after infrapopliteal interventions. Freedom from MACE (ACEI/ARB 37% vs 32%, P=.82) and overall survival (ACEI/ARB 42% vs 35% No ACEI/ARB, P= .84) were not significantly different. CONCLUSIONS ACEI/ARB are associated with improved limb salvage in CLI patients undergoing infrapopliteal interventions, but not after femoropopliteal interventions. ACEI/ARB had no impact on patency rates. They were also associated with a trend towards improved survival and freedom from MACE. Our findings suggest that the use of ACEI/ARB may improve outcomes in the high-risk CLI patient population.