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Published on: September 22, 2020
Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require
K Noronen1, E Saarinen2, A Albäck2
1Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland.
Insights
Timely revascularisation is crucial for critical limb ischaemia (CLI) patients, especially diabetics. Delays beyond two weeks significantly worsen limb salvage outcomes, highlighting the need for rapid vascular evaluation and treatment.
Area of Science:
- Vascular Surgery
- Diabetic Foot Care
- Ischaemic Limb Management
Background:
- Critical limb ischaemia (CLI) is increasing due to an aging population.
- Tissue loss in CLI carries a high risk of major amputation.
- Understanding treatment delays is vital for improving limb salvage rates.
Purpose of the Study:
- To analyze the treatment pathway for CLI patients from referral to revascularisation.
- To identify delays and their underlying causes.
- To determine which patients benefit most from early revascularisation.
Main Methods:
- Retrospective analysis of 394 patients (447 limbs) with suspected ischaemic tissue loss.
- Data collected on referral, treatment strategies (endovascular vs. open surgery), and outcomes.
- Multivariate analysis to identify factors influencing limb salvage.
Main Results:
- Revascularisation was scheduled for 246 limbs; 221 underwent endovascular treatment (ET), 45 open surgery (OS).
- Median time to revascularisation was 43 days; no significant difference between ET and OS.
- Diabetes was associated with poorer limb salvage; delays >2 weeks significantly worsened outcomes in diabetic patients.
Conclusions:
- Diabetic ulcers necessitate prompt vascular evaluation.
- Rapid diagnostics and revascularisation, ideally within 2 weeks, are essential for optimal limb salvage in suspected CLI.
- Early intervention is key to preventing amputation in vulnerable diabetic populations.
Objectives:
The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation.
Methods:
A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin.
Results:
For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population, with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients.
Conclusions:
Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation.
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