Study Analyzes Nationwide Critical Limb Ischemia Treatment Trends

March 23, 2016—A study of nationwide trends of hospital admission and outcomes among critical limb ischemia (CLI) patients from 2003 through 2011 was published online ahead of print in the Journal of the American College of Cardiology (JACC) by Shikhar Agarwal, MD; Karan Sud, MD; and Mehdi H. Shishehbor, DO.

As reported in JACC, the study included 642,433 admissions with CLI from 2003 to 2011. The annual rate of CLI admissions has been relatively constant across 2003 to 2011 (approximately 150 of every 100,000 people in the United States). The proportion of patients undergoing surgical revascularization was reduced from 13.9% in 2003 to 8.8% in 2011, while endovascular revascularization increased from 5.1% to 11% during the same time period. This was accompanied by a steady reduction in the incidence of in-hospital mortality and major amputation. The mean length of stay and mean cost of hospitalization were also shown to be reduced.

In comments to Endovascular Today, Dr. Shishehbor detailed the study’s findings, which include that any revascularization was directly associated with lower rates of major amputations and decreased mortality. Additionally, endovascular revascularization was associated with lower mortality, hospital length of stay, and cost when compared to open surgical bypass. Dr. Shishehbor is the Director of Endovascular Services in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at the Cleveland Clinic in Cleveland, Ohio.

The investigators also observed that rates of mortality and amputations have declined in the last decade despite a significant increase in the prevalence of diabetes, obesity, hypertension, and other comorbidities. However, Dr. Shishehbor commented that persistent disparities exist by race and geography, whereby black patients were noted to have a higher rate of major amputations but a lower rate of revascularization.

Dr. Shishehbor told Endovascular Today these findings suggest that, if appropriate, all patients should be considered for revascularization before any amputation, and that an endovascular approach seems to be the “first-line therapy” in a majority of the patients. He added, “We need to do a better job to treat comorbidities such as diabetes, obesity, and hypertension. We must address disparities in amputation and revascularization rates in the United States.”

Going forward, Dr. Shishehbor emphasized the need to identify centers of excellence that can treat complex disease. "No patient should undergo an amputation because of lack of resources, operator or institutional inexperience, or because of race or geography. We must understand why such disparities exist and seek to correct them,” he said.