Not All Patients with Critical Limb Ischaemia Require Revascularisation
T B Santema1, R M Stoekenbroek1, J van Loon1
1Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
Insights
Critical limb ischaemia (CLI) patients treated conservatively showed similar amputation-free survival (AFS) and overall survival (OS) to those undergoing revascularisation. Further research is needed to identify which CLI patients can safely omit revascularisation.
Area of Science:
- Vascular Surgery
- Clinical Outcomes Research
- Patient Management
Background:
- International guidelines advocate revascularisation for critical limb ischaemia (CLI).
- Limited data exists on the outcomes of conservative management for CLI.
- This study investigates amputation-free survival (AFS) and overall survival (OS) in CLI patients with varying treatment approaches.
Purpose of the Study:
- To compare AFS and OS in CLI patients who received immediate revascularisation, delayed revascularisation, or conservative treatment.
- To identify factors associated with clinical outcomes in CLI patients.
Main Methods:
- Retrospective cohort study of 144 CLI patients (2010-2014) in a Dutch university hospital.
- CLI defined by ischemic rest pain or tissue loss with specific ankle/toe pressures.
- Patients categorized into immediate invasive, deferred invasive, or conservative groups; survival analyses performed.
Main Results:
- 66.7% of patients underwent revascularisation within 6 weeks; 18.1% had deferred treatment; 15.3% received conservative care.
- No significant difference in AFS or OS was observed between the three treatment groups.
- Age, COPD, heart disease, and hypertension were independent predictors of survival, but treatment type was not.
Conclusions:
- Conservative management may yield similar AFS and OS to revascularisation in some CLI patients.
- The optimal treatment strategy for CLI remains unclear.
- Prospective studies are needed to identify patient subgroups who may not require revascularisation.
Objectives:
International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored.
Methods:
This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS.
Results:
The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS.
Conclusions:
Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.
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