GLASS of the foot: is the pedal arch modifier a useful tool or a confounding factor?
DOI:
https://doi.org/10.48750/acv.692Keywords:
Chronic limb-threatening ischemia, Global limb anatomic staging system, Pedal arch, Inframalleolar diseaseAbstract
Introduction
The Global Limb Anatomic Staging System (GLASS) has become a widely adopted tool for guiding treatment planning and prediction of revascularization success in chronic limb-threatening ischemia (CLTI). However, the proposed pedal modifier was not included in the initial validation studies and information on its value as an adjunct of the classification remains scarce.
Our aim was to evaluate the pedal modifier as a predictor for wound healing and major adverse limb events (MALE) after primary endovascular CLTI revascularization.
Methods
We conducted a retrospective analysis of patients who underwent their first endovascular revascularization for CLTI at a tertiary center between 2020 and 2021. Patients with no available diagnostic angiography were excluded. Electronic medical records were reviewed and angiographic imaging was used to classify each procedure according to their GLASS score including the pedal modifier. Adverse limb events were documented at 30-days, 3, 6 and 12 months.
Results
A total of 118 patients were included in the study. Most patients (83.1%) presented with Rutherford 5 chronic limb ischemia and evenly distributed GLASS severity score (I 15.3%, II 40.7%, III 43.2%). Concerning pedal arch anatomy, 91.5% had at least one artery crossing the ankle to the foot with varying degrees of arch disease-burden. A fully intact arch with minimal disease (P0) was observed in 32.2% of cases, while 53.4% had a diseased or absent arch (P1). Only 14.4% of patients had no named artery crossing the ankle (P2). The median follow-up was 12 months (IQR 6) with a MALE incidence of 34.9% (9.3% major amputation, 33.9% reintervention due to primary revascularization failure). Fifty-seven percent (61%) of patients achieved adequate wound healing during follow-up.
After stratification based on the pedal modifier, the three groups (P0, P1 and P2) were comparable concerning demographic and clinical variables. The outcome-related variables did not show any significant difference either isolated or on a sub-analysis after grouping for pedal GLASS severity.
Discussion
Despite growing recognition of the role of anatomic disease burden in CLTI management, the predictive value of the GLASS pedal modifier remains unclear. Our findings suggest that pedal arch patency may not significantly influence revascularization success or amputation-free survival and confirmation of our results in a large data multicentric studies could lead to a paradigm shift.
Downloads
References
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019;58:S1-S109.
lida O, Soga Y, Hirano K, Kawasaki D, Suzuki K, Miyashita Y, et al. Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. J Vasc Surg. 2012;55:363-70.
Alexandrescu VA, Brochier S, Schoenen S, Antonelli E, Azdad K, Zekhnini I, et al. Grades of Below-the-Ankle Arterial Occlusive Disease following the Angiosome Perfusion: A New Morphological Assessment and Correlations with the Inflamalcelar GVG Stratification in CLTI Patients. Ann Vasc Surg. 2022;81:358-77.
Morisaki K, Matsuda D, Matsubara Y, Kurose S, Yoshino S, Kinoshita G, et al. Global Limb Anatomic Staging System Inflamalcelar Modifier Predicts Limb Salvage and Wound Healing in Patients with Chronic Limb Threatening Ischemia Undergoing Endovascular Inflamingul Revascularisation. Eur J Vasc Endovasc Surg. 2023;65:391-97.
Ji S, Hou X, Zhang X, Wu Z, Lin J, Lin Y, et al. The Relationship Between the Global Limb Anatomic Staging System Inflamalcelar Modifier and the Outcomes of Diabetic Foot Ulcer with Peripheral Artery Disease. Ann Vasc Surg. 2023;92:256-63.
Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517-38.
Miyake K, Kikuchi S, Uchida D, Doita T, Miyagawa S, Azuma N. The impact of angiographic pedal circulation status on wound healing in chronic limb-threatening ischemia after bypass surgery. J Vasc Surg. 2024;80:1836-46.
Toyoshima T, lida O, Hata Y, Okamoto S, Ishihara T, Nanto K, et al. Effects of Infra-malleolar Status According to Global Limb Anatomic Staging System on Clinical Outcomes in Patients With Chronic Limb-Threatening Ischemia. Angiology. 2023;74:79-87.
Wijnand JGJ, Zarkowsky D, Wu B, van Haelst STW, Vonken EPA, Sorrentino TA, et al. The Global Limb Anatomic Staging System (GLASS) for CLTI: Improving Inter-Observer Agreement. J Clin Med. 2021;10(16):3454.
