Medial Arterial Calcification Score Predicts Wound Healing and Major Amputation in Patients with Chronic Limb-Threatening Ischemia and Inframalleolar Lesions Undergoing Endovascular Therapy: Results from the MAVERICK Study

Abstract

Purpose:

To identify prognostic factors for wound healing and major amputation in patients with chronic limb-threatening ischemia (CLTI) and inframalleolar lesions undergoing endovascular therapy (EVT).

Materials and methods:

We conducted a multicenter, retrospective observational study involving 401 limbs in 318 patients with Rutherford classification 5 to 6 and inframalleolar disease treated with EVT between January 2018 and August 2022. The primary endpoint was 6-month wound healing, and the secondary endpoint was 1-year freedom from major amputation. We used the Cox proportional hazards models to identify independent predictors.

Results:

The 6-month wound healing rate was 48.2%, and the 1-year freedom from major amputation was 87.9%. Rutherford classification 6 (hazard ratio [HR]=0.69; 95% confidence interval [CI]=0.50–0.95; p=0.022) and each 1-point increase in the medial arterial calcification (MAC) score (HR=0.84; 95% CI=0.77–0.93; p<0.001) were independently associated with delayed wound healing. Wound, Ischemia, and foot Infection (WIfI) clinical stage of 4, small artery disease (SAD) score 2, and a higher MAC score were significantly associated with an increased risk of major amputation.

Conclusion:

The MAC score independently predicts delayed wound healing and major amputation in patients with CLTI and inframalleolar lesions undergoing EVT, supporting its use in preprocedural risk stratification.

Clinical Impact

This multicenter observational study highlights the prognostic value of integrating anatomical and clinical severity scores—medial arterial calcification (MAC), small artery disease (SAD), Wound, Ischemia, and foot Infection (WIfI), and Rutherford classifications—into preprocedural risk stratification for patients with chronic limb-threatening ischemia (CLTI) undergoing endovascular therapy (EVT). Identifying high MAC or SAD scores as independent predictors of poor outcomes underscores the need for personalized treatment planning. Clinicians can use these scores to guide EVT candidacy, optimize revascularization strategies, and anticipate wound healing and amputation risks. This evidence supports a shift toward more tailored, data-driven management approaches in high-risk CLTI populations, potentially improving limb salvage and patient outcomes in everyday vascular practice.