Heart Failure Predicts Contralateral Limb Progression After Endovascular Therapy for Initial Unilateral Chronic Limb-Threatening Ischemia

Background: Heart failure (HF) is associated with adverse outcomes in patients with peripheral artery disease. However, its impact on contralateral limb progression after endovascular therapy (EVT) for chronic limb-threatening ischemia (CLTI) remains unclear. This study investigated the association between HF and contralateral major adverse limb events (MALE) after EVT for initial unilateral CLTI. Methods: We retrospectively analyzed patients with initial unilateral CLTI from the multicenter registry. Patients with prior contralateral CLTI or contralateral major amputation were excluded. The primary outcome was contralateral MALE, defined as a composite of contralateral revascularization and major amputation. Secondary outcomes included recurrent contralateral CLTI, contralateral EVT, contralateral major amputation, and ipsilateral MALE. Kaplan–Meier analysis and Cox proportional hazards models were used. Results: Among 347 patients, 182 had HF. During follow-up, contralateral MALE occurred in 86 patients. Patients with HF had significantly lower freedom from contralateral MALE than those without HF (63.9% vs 80.3%, log-rank P = .002). In multivariable analysis adjusting for age, sex, diabetes mellitus, dialysis, albumin <3.0 g/dL, cerebrovascular disease, and coronary artery disease, HF remained independently associated with contralateral MALE (adjusted HR 2.08, 95% CI 1.29-3.35, P = .003). Heart failure was also independently associated with contralateral EVT (adjusted HR 2.06, 95% CI 1.29-3.28, P = .003), but not with ipsilateral MALE (adjusted HR 1.08, 95% CI 0.77-1.51, P = .66). Conclusions: In patients undergoing EVT for initial unilateral CLTI, HF independently predicted contralateral limb events but not ipsilateral limb failure. These findings suggest that HF may identify patients who warrant closer clinical assessment of the contralateral limb after EVT. Clinical Impact Heart failure (HF) is a well-established predictor of mortality in patients with chronic limb-threatening ischemia (CLTI), but its association with subsequent limb events has remained unclear. In this multicenter study, HF was independently associated with contralateral major adverse limb events and contralateral revascularization after endovascular therapy, whereas no association was observed with ipsilateral MALE. These findings suggest that HF may help identify patients at increased risk for future contralateral limb events. Incorporating HF status into post-EVT risk assessment may support closer surveillance of the contralateral limb and facilitate earlier detection of clinically significant disease requiring intervention.