Reply: Broadening the Risk Model for Acute Limb Ischemia in Post-Cardiac Surgery Patients

Dear Editor,

We sincerely thank Dr. Gökhan Ceyhun for his thoughtful comments and for the interest shown in our article on Acute Limb Ischemia (ALI) after Cardiovascular Surgery. We appreciate his insights emphasizing additional prognostic factors that may influence postoperative outcomes.[1]

We fully agree that the prognosis of ALI following cardiac surgery is multifactorial. Indeed, parameters such as advanced age, reduced left ventricular ejection fraction, chronic kidney disease, and the urgency of the surgical procedure reflect the frailty and comorbidity burden that significantly affect outcomes. Our study primarily focused on intraoperative and immediate postoperative variables, including cardiopulmonary bypass (CPB) duration and acute kidney injury (AKI), which were statistically significant in predicting 1-year mortality. Moreover, our study population did not have advanced age in either group, with a median age of 59 (23–72) years in the mortality group and 47 (33–71) years in the non-mortality group, with no significant difference between the two groups (p = 0.067). There is also no significant difference between the mortality and non-mortality groups in terms of ejection fraction <40% (p = 0.468) and urgent or emergency surgery parameter (p = 0.780). Nonetheless, the integration of preoperative and systemic factors, as Dr. Ceyhun highlighted, would undoubtedly enhance the predictive accuracy of risk models.

We also concur that the use of mechanical circulatory support devices such as extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pump (IABP) represents an important consideration. These devices can compromise distal limb perfusion and are well-documented contributors to postoperative ischemic complications. Unfortunately, due to the limited sample size and the retrospective nature of our study, we could not perform a robust subgroup analysis to evaluate their independent effect on long-term survival. In addition, in our study, there was no significant difference in baseline characteristics regarding IABP insertion between the mortality and non-mortality groups (p = 0.438).

Regarding systemic complications such as sepsis and reperfusion injury, we acknowledge their critical role in worsening outcomes. The interplay among systemic inflammatory response, metabolic derangements, and ischemia–reperfusion injury underscores that ALI should indeed be viewed as part of a broader systemic process rather than an isolated vascular event.

We appreciate Dr. Ceyhun's constructive remarks, which reinforce the need for comprehensive, multicenter prospective studies incorporating both patient-specific and perioperative factors. Such approaches will be essential for developing accurate prognostic tools and improving prevention and management strategies in this high-risk patient population.

Publication History

Article published online:
31 December 2025

• Reference

• 1 Ceyhun G. Broadening the Risk Model for Acute Limb Ischemia in Post-Cardiac Surgery Patients. Int J Angiol 2025; (ahead of publication)