Textbook outcomes remain “very rare” after revascularization for chronic limb-threatening ischemia (CLTI), with the main driver being an enduring inability to attain complete wound healing and to return patients to their preoperative ambulatory status, according to the lead researcher behind a new study looking into a version of the performance outcome metric.
Jayer Chung, MD, an associate professor in the Division of Vascular Surgery and Endovascular Therapy at the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, in Houston, Texas, was speaking to Vascular Specialist shortly after presenting data at the 2025 Southern Association for Vascular Surgery (SAVS) annual meeting in St. Thomas, the U.S. Virgin Islands (Jan. 22–25), describing how current outcome metrics do not capture the totality of a patient’s CLTI journey.
“Textbook outcomes at one year were rare,” Chung told SAVS 2025. “They occurred in less than quarter of our population. And what’s significant is that when you split the [textbook outcome] composite, we see that the traditional metrics used to measure clinical success such as survival, limb salvage, freedom from 30-day complications were met,” he continued. “Yet, many of the patient-centric metrics such as wound healing, ambulation and freedom from wound-related procedures were not met. Complete wound healing and a return to ambulatory status were achieved in approximately two thirds, almost half of our patients underwent another revascularization at one year, and only two thirds of our patients were able to get by with one or less wound-related procedure.”
Chung and colleagues performed a nine-year retrospective, single-center analysis of consecutive CLTI patients undergoing revascularization (open, endovascular or hybrid). Textbook outcome was defined as a composite of survival, limb-salvage, no reinterventions (wound or vascular), freedom from major complications, less than one wound-related procedure and complete wound-healing at one year.
“Patients with WIfI [wound ischemia and foot infection] stage 1 had more than 2.5-fold odds of achieving a textbook outcome compared to all of the other WIfI stages, whereas taking anticoagulants at baseline, diabetes at baseline or residing in an assisted living facility were independently less likely to achieve a textbook outcome,” Chung added during SAVS 2025. “In our opinion, current performance metrics overlook the true procedural burden of revascularization, therefore we feel that our definition of textbook outcomes should be factored into future patient education and treatment selections, in outcome evaluations, in clinical trials and quality assessments.”
Chung later expanded on why he believes the textbook outcome metric better elucidates CLTI care.
“Our current outcome metrics fail to capture the full depth and scope of the patient experience,” he told Vascular Specialist. “It misses particular functional outcomes like ambulation and domiciliary status, as well as fails to truly capture the impact of wound care and the progress that patients have on the journey to try and salvage their limb. The current metrics that are used to track performance across clinical trials or quality assessments, for instance, overestimate the quality of care that is being given. It causes us to misappropriate resources to some extent, as well as misjudge the true quality when we are comparing two different therapies.”
Chung added: “I think utilizing a comprehensive metric like textbook outcome to adjudicate and help educate our patients ahead of time is going to be critical going forward as we try to improve the care of our patients overall.”
