Trends in the Treatment of Critical Lower Limb Ischemia

Approximately 25% of patients with critical lower limb ischemia (CLLI) face amputation within the first year after diagnosis (according to statistics from the United States). Proper assessment of these patients should include angiography and revascularization before considering amputation. However, between 2009 and 2015, there was a 50-% increase in amputations, often without appropriate revascularization.

The objective of this retrospective study was to assess revascularization alternatives (endovascular or surgical), their variations, and outcomes in US national centers using data from Medicare patients. The study included patients aged 66 or older diagnosed with CLLI who underwent infrainguinal revascularization between 2015 and 2021.

The primary endpoint was major amputation of the affected limb within a year after revascularization. Secondary endpoints included amputation or death, death, repeat procedure, and minor amputation during the same period.

Out of 196,070 patients diagnosed with CLLI, 82.5% underwent endovascular treatment. The average age was 73.5 years. Patients selected for endovascular treatment tended to be older and had a higher burden of comorbidities than the other patients, and most of them were women. In contrast, those undergoing surgical bypass had higher rates of smoking and reports of pain at rest.

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Among patients initially treated with an endovascular approach, 1.8% required surgery before amputation. The most common technique was angioplasty with atherectomy (15.5%), followed by angioplasty alone (44.4%). There was significant variability in the choice of revascularization strategy among institutions (median odds ratio [MOR]: 2.37).

In high-volume centers that prioritized endovascular revascularization as the first-line option, the rates for major amputation were lower (adjusted hazard ratio [aHR]: 0.82; 95% confidence interval [CI]: 0.77-0.88; P <0.01) while the rates of reintervention were higher (aHR: 1.37; 95% CI: 1.32-1.43; P <0.01), with no significant differences in mortality or minor amputation.

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As regards surgical treatment, high-volume centers had higher rates of major amputation (aHR: 1.21; 95% CI: 1.13-1.29; P <0.01) and lower frequencies of repeat procedures (aHR: 0.73; 95% CI: 0.70-0.76; P < 0.01), with no differences in mortality or minor amputation rates.

Conclusions

This analysis of Medicare patient records revealed considerable variability among centers in revascularization strategies for CLLI. Centers prioritizing endovascular treatment as the first-line option achieved lower rates of major amputation without impacting mortality. This study, based on real-world data, highlights the importance of procedural expertise in reducing adverse events.

Original Title: Variations in Revascularization Strategies for Chronic Limb-Threatening Ischemia.

Reference: Raja A, Song Y, Li S, Parikh SA, Saab F, Yeh RW, Secemsky EA. Variations in Revascularization Strategies for Chronic Limb-Threatening Ischemia: A Nationwide Analysis of Medicare Beneficiaries. JACC Cardiovasc Interv. 2024 Dec 20:S1936-8798(24)01209-3. doi: 10.1016/j.jcin.2024.09.024. Epub ahead of print. PMID: 39797832.