Limited Prognostic Value of Psoas Muscle Indices in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

<b>Background:</b> Sarcopenia is linked with high rates of adverse surgical outcomes, and computed tomography angiography (CTA)-based psoas measurements are used as imaging sarcopenia surrogates. Their prognostic value in patients with chronic limb-threatening ischemia (CLTI) undergoing revascularization remains uncertain. <b>Objectives:</b> To evaluate whether CTA-derived psoas muscle indices predict complications and mortality after lower-limb revascularization for CLTI. <b>Methods:</b> We performed a retrospective cohort study of consecutive adults who underwent open, hybrid, or endovascular revascularization for CLTI at a single tertiary center (March 2018-December 2021). Psoas muscle area (PMA) and density (PMD) were measured preoperatively on CTA at the mid-L3 vertebral level. Psoas muscle index (PMI) was calculated as PMA/height². Patients were stratified by tertiles for each index (lowest tertile = "sarcopenic" vs. upper two tertiles). Outcomes included early in-hospital complications, late complications, overall complications, late mortality, and overall mortality. Group comparisons used χ²/Fisher tests with false discovery rate (FDR) adjustment; multivariable logistic regression with AIC-guided selection assessed independent predictors. <b>Results:</b> A total of 234 patients were included (median age 68 years; 65.4% men). Early complications occurred in 15.8%; late complications in 70.3%; overall mortality during follow-up was 26.6% (38/143 within follow-up data). In tertile analyses, none of the psoas-derived measures were significantly associated with early complications, late complications, overall complications, or mortality after FDR correction. Lower PMD showed consistent but non-significant trends toward higher late complications (84% vs. 64%), overall complications (87% vs. 72%), overall mortality (38% vs. 21%), and late mortality (37% vs. 20%) (all <i>p</i> < 0.05 unadjusted; all p_adj ≥ 0.139). In multivariable models, PMA, PMD, and PMI were not independent predictors of any outcome. <b>Conclusions</b>: In this retrospective cohort study, preoperative CTA-derived psoas indices were not independent predictors of early, late, or overall complications, nor of in-hospital or follow-up mortality after revascularization for chronic limb-threatening ischemia. Although lower psoas muscle density showed consistent trends toward higher risk, these associations did not reach statistical significance after adjustment. Taken together, our findings suggest that psoas-based measures have limited prognostic value in this setting and should be interpreted cautiously, while their potential role warrants confirmation in larger, prospective studies.