Amputation rate and mortality in elderly patients with critical limb ischemia not suitable for revascularization

In spite of recent progress in revascularization and anesthesiology procedures, in vascular centers today there are still patients with Critical Limb Ischemia (CLI) who are not considered suitable for revascularization. Most of these patients are elderly, with high co-morbidity factors, poor run off arterial limb vessels, and often with a salvageable limb. They are absent or neglected in the literature, and generally go untreated. We report details of 24- month amputations and mortality rates in 90 patients with CLI who were not considered suitable for revascularization, treated from 2005 to 2008 in a dedicated unit of our department. Patients with endstage general conditions or needing immediate primary amputation were excluded from our study. All patients received multidisciplinary assessment. Their median age was 78.4 years; 28 patients (31.1%) had rest pain only, and 62 (68.8%) had ischemic skin foot-leg wounds or gangrene <2 cm. Sixteen patients (37.7%) were assessed as not suitable for revascularization because of poor functional status, and 76 (64.4%) because of inadequate outflow limb vessels. Drugs to manage pain were administered to all patients (100%), prostanoid infusions were given to 80 (88%), anti-platelet drugs to 87 (96%), low molecular weight heparin or oral anticoagulants to 13 (14%), spinal cord stimulation to 3 (3%), hyperbaric oxygen treatment to 16 (17%) and wound treatment to 62 (68.8%). Toe or other foot-sparing amputations had a rate of 13%. After 24 months, the major amputation rate was 9.3% and the mortality rate 23.2%. Our observations show that, in spite of progress in revascularization procedures, there are still patients with CLI who are not considered suitable for revascularization and who could benefit from non-surgical treatment if a tailored approach is used.