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Published on: September 22, 2020
Decision-Making in Critical Limb Ischemia: A Markov Simulation
Aaron J Deutsch1, C Charles Jain2, Kimberly G Blumenthal3
1Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA; Harvard-MIT Division of Health Sciences and Technology, Harvard Medical School, Boston, MA.
Insights
For critical limb ischemia (CLI), endovascular therapy and surgical bypass offer similar outcomes, both superior to amputation or medical management. Long-term survival rates significantly influence the choice between endovascular and surgical approaches.
Area of Science:
- Vascular Surgery
- Decision Modeling
- Health Economics
Background:
- Critical limb ischemia (CLI) is a severe complication of peripheral vascular disease.
- Management often involves complex decisions for patients with comorbidities like heart failure and diabetes.
- A decision model was created to evaluate treatment strategies for a specific patient profile.
Observation:
- A Markov decision model compared amputation, surgical bypass, endovascular therapy, and medical management.
- Sensitivity analyses were performed to assess the impact of parameter uncertainty.
- Quality-adjusted life months (QALMs) were used as the primary outcome measure.
Findings:
- Endovascular therapy and surgical bypass demonstrated comparable effectiveness in the base case (26.50 vs. 26.34 QALMs).
- Both revascularization strategies significantly outperformed amputation (18.83 QALMs) and medical management (11.08 QALMs).
- Results remained robust across various mortality and utility weight scenarios, though long-term mortality was a key sensitivity factor.
Implications:
- Endovascular therapy and surgical bypass are viable, comparable options for CLI management.
- The choice between endovascular and surgical approaches should consider procedure-specific long-term mortality.
- Both advanced revascularization techniques offer superior outcomes compared to amputation or conservative medical treatment for CLI patients.
Background:
Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. We developed a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes.
Methods:
We developed a Markov decision model to evaluate 4 strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multiway sensitivity analyses.
Results:
In the base case, endovascular therapy yielded similar discounted quality-adjusted life months (26.50 QALMs) compared with surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs) and medical management (11.08 QALMs). This finding was robust to a wide range of periprocedural mortality weights and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values.
Conclusions:
For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.
