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Critical and subcritical ischaemia
Insights
This study stratifies leg ischemia patients into low-risk (subcritical) and high-risk (critical) groups. High-risk patients benefit significantly from arterial reconstruction, improving limb salvage rates compared to conservative treatment.
Area of Science:
- Vascular Surgery
- Clinical Outcomes Research
- Peripheral Artery Disease
Background:
- Critical leg ischemia poses a significant risk of major amputation and mortality.
- Accurate risk stratification is essential for guiding treatment decisions and improving patient outcomes.
- Current classifications may not adequately differentiate between risk levels, impacting study interpretations.
Purpose of the Study:
- To stratify patients with leg ischemia into distinct high-risk and low-risk groups.
- To analyze the outcomes (limb salvage and mortality) for each risk group.
- To provide a more realistic perspective on the effectiveness of reconstructive surgery.
Main Methods:
- Systematic evaluation of 20 publications encompassing 6118 patients with critical leg ischemia.
- Identification of low-risk (subcritical) and high-risk (critical) groups based on defined clinical and hemodynamic criteria (ankle pressure > 40 mmHg vs. < 40 mmHg, presence of tissue loss).
- Analysis of patient and limb outcomes, including major amputation and mortality rates, with and without surgical intervention.
Main Results:
- Two distinct groups were identified: subcritical (n=4089) and critical (n=2029).
- Overall 1, 3, and 5-year mortality rates were 26%, 44%, and 56%, respectively.
- For high-risk patients, conservative treatment led to 95% amputation, while arterial reconstruction reduced this to 25%; limb salvage was 93% with reconstruction.
- Low-risk patients had a 27% chance of limb salvage with conservative treatment.
Conclusions:
- Reconstructive surgery outcomes should be interpreted within the context of patient risk stratification.
- For high-risk critical ischemia, 100% arterial patency correlates with 93% limb salvage at one year.
- Future research must differentiate between subcritical and critical ischemia groups to accurately assess treatment efficacy and guide pharmacotherapy trials.
Objectives:
To stratify leg ischaemia into high and low risk groups with respect to outcome.
Methods:
An evaluation of 20 recent publications, reporting the results of 6118 patients with critical ischaemia. Low and high risk patient groups are identified by the definition of critical ischaemia. These groups are analysed with respect to outcome of the patient and limb.
Main Outcome Measures:
Major amputation and mortality.
Results:
From these data subcritical (rest pain and/or ankle pressure > 40 mmHg, n = 4089) and critical (tissue loss and/or ankle pressure < 40 mmHg, n = 2029) risk group of patients was identified. The 1, 3 and 5-year mortality is 26%, 44% and 56% with or without reconstruction. For patients in the low risk group, 27% did not lose their leg within the year if treated conservatively. For patients in the high risk group, amputation was required by 95% if treated conservatively, compared to 25% if treated with arterial reconstruction.
Conclusion:
Reconstructive surgery should be viewed from the following, more realistic, perspective. For patients with rest pain (and/or ankle pressure > 40 mmHg), 100% cumulative patency is equivalent to 64% resolution of symptoms at 1 year, as the rest may have improved without treatment. For high risk patients (tissue loss and/or ankle pressure < 40 mmHg), 100% cumulative patency is equivalent to 93% limb salvage at 1 year. Future reports should identify these two groups separately, as the dominant difference between outcome studies is the proportion of subcritical patients in the study rather than better surgical or radiological techniques. This stratification also has an important bearing on pharmacotherapy trials.