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PRE-oPerative Assessment for Patients with Chronic Limb ThReatening IschEmia (PREPARE): A Multinational Delphi
Stacie Hodge1, Jane Lowry2, Frank Bowling3
1Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, UK; Manchester Academic Vascular Research and Innovation Centre (MAVRIC), Manchester University NHS Foundation Trust, Manchester, UK.
Insights
Vascular specialists reached consensus on perioperative care for chronic limb-threatening ischemia (CLTI), emphasizing multidisciplinary teams and selective investigations. Further research is needed for risk prediction tools in CLTI management.
Area of Science:
- Vascular Surgery
- Patient Management
- Clinical Consensus
Background:
- Chronic limb-threatening ischemia (CLTI) poses diagnostic and management challenges.
- A lack of standardized preoperative assessment and optimization frameworks exists for CLTI patients.
- This study aimed to establish expert consensus on perioperative care for CLTI.
Purpose of the Study:
- To develop a contemporary consensus among vascular specialists on the perioperative care of CLTI patients.
- To address challenges in diagnosis and management of CLTI.
- To create standardized frameworks for preoperative assessment and optimization.
Main Methods:
- Modified Delphi methodology with 42 vascular surgeons from UK, Ireland, Australia, and New Zealand.
- Exploration of four domains: service availability, preoperative assessment, perioperative optimization, and multidisciplinary teams (MDTs).
- Consensus defined as ≥70% agreement.
Main Results:
- 59 consensus statements were established, including rapid access clinics and anemia management.
- Unanimous agreement on clear referral pathways and strong support for MDTs in complex cases.
- Significant uncertainty regarding risk prediction models (53% agreement); 81% agreed investigations changing intervention type should precede surgery.
Conclusions:
- CLTI management requires a multifaceted, interdisciplinary approach.
- Recommendations include improved primary care, selective preoperative investigations, and emphasis on interdisciplinary care.
- Ongoing uncertainties in risk prediction necessitate further research to validate tools and practices for improved patient outcomes.
Background:
Chronic limb-threatening ischemia (CLTI) presents significant challenges in both diagnosis and management, with a lack of standardized preoperative assessment and optimization frameworks. This study aimed to establish a contemporary consensus among vascular specialists on the perioperative care of CLTI patients across diverse health-care systems.
Methods:
A modified Delphi methodology was used, involving iterative rounds of consultation with 42 expert vascular surgeons from the United Kingdom, Ireland, Australia, and New Zealand. Four broad domains were explored: availability of services, preoperative assessment, perioperative optimization, and the role of multidisciplinary teams (MDTs). Consensus was defined as ≥70% agreement RESULTS: A total of 59 consensus statements were established, covering key areas such as rapid access clinics, the value of preoperative investigations and anemia. Unanimous agreement was reached regarding the necessity of clear referral pathways, and a strong majority supported the importance of MDTs in complex cases. However, significant uncertainty remained about the utility of existing risk prediction models, with only 53% endorsing tools like the American College of Surgeons Risk Calculator. Notably, 81% agreed that if preoperative investigations could change the type of intervention a patient received, this investigation should be performed prior to surgery even at the expense of delayed intervention.
Conclusion:
This Delphi consensus study highlights the complexity in managing patients with CLTI and the necessity of a multifaceted, interdisciplinary approach to preoperative care. The findings advocate for improved primary care management, selective use of preoperative investigations and emphasizes the importance of interdisciplinary care. While consensus was reached on several key aspects of care, the study highlights ongoing uncertainties around risk prediction and cardiac stress testing therefore highlighting the need for further research to validate current tools and practices. These results lay the groundwork for future clinical guidelines aimed at reducing practice variability and improving patient outcomes.
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