Original title: Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence. Reference: Reinecke H et al. Eur Heart J. 2015; Epub ahead of print.
This work included 41882 patients retrospectively from health insurance in Germany admitted with diagnosis of peripheral vascular disease between 2009 and 2011 and followed until 2013.
Patients were divided according to the Rutherford classification into categories 1-2-3 (n = 21197), Category 4 (n = 5353), Category 5 (n = 6916) and category 6 (n = 8416). The proportion of patients with classic risk factors such as hypertension, dyslipidemia and smoking decreased as Rutherford class increased (p <0.001 for all) unlike what happened with diabetes, chronic kidney disease and heart failure that increased as Rutherford class increased (p <0.001 for all).
Angiography and revascularization procedures were performed less frequently in patients with more advanced peripheral vascular disease (p <0.001). Amputations increased steadily from 0.5% in class 1-2-3 to 42% in class 6 like heart attacks, strokes and death (p <0.001 for all). From 4298 amputations in patients with critical limb ischemia, 37% did not receive angiography and revascularization during the index hospitalization or in the previous two years. During follow-up (mean 3 years), 7825 patients were amputees and 10880 died.
The projected mortality at four years according to Kaplan-Meier will reach 18.9%, 37.7%, 52.2% and 63.5% for Rutherford classes 1-3, 4, 5 and 6 respectively and the risk of amputation in the same period of time will reach 4.6%, 12.1%, 35.3% and 67.3% respectively. In the multivariate analysis Rutherford class was an independent predictor of death, myocardial infarction, stroke and amputation (p <0.001 for all).
Conclusion
Despite recent advances in treating peripheral vascular disease, actual results remain poor, especially for critical ischemia. Despite the evidence for revascularization to prevent amputations, patients with critical ischemia still receive significantly less treatment than they should.
Editorial comment
The mortality observed in patients with critical ischemia has not changed since publication of the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) published over 10 years ago. Possible explanations could be advanced systemic disease in patients with critical ischemia, comorbidities such as diabetes and heart failure, and the use of sub procedures. This latter is directly in the hands of the Interventionist and should not be under estimated.
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