Impact of Comorbidities on Decision-Making in Chronic Critical Limb Ischemia

Emerging trends in nationwide mortality, limb loss, and resource utilization for critical limb ischemia in young adults

BACKGROUND/OBJECTIVES

Recent trends indicate a rise in the incidence of critical limb ischemia (CLI) among younger adults. This study examines trends in CLI hospitalization and outcomes among young adults with peripheral arterial disease (PAD) in the United States.

METHODS

Adult hospitalizations (18-40 years) for PAD/CLI were analyzed from the 2016-2020 nationwide inpatient sample database using ICD-10 codes. Rates were reported per 1000 PAD or 100,000 cardiovascular disease admissions. Outcomes included trends in mortality, major amputations, revascularization, length of hospital stay (LOS), and hospital costs (THC). We used the Jonckheere-Terpstra tests for trend analysis and adjusted costs to the 2020 dollar using the consumer price index.

RESULTS

Approximately 63,045 PAD and 20,455 CLI admissions were analyzed. The mean age of the CLI cohort was 32.7 ± 3 years. The majority (12,907; 63.1 %) were female and white (11,843; 57.9 %). Annual CLI rates showed an uptrend with 3265 hospitalizations (227 per 1000 PAD hospitalizations, 22.7 %) in 2016 to 4474 (252 per 1000 PAD hospitalizations, 25.2 %) in 2020 (Ptrend<0.001), along with an increase in PAD admissions from 14,405 (188 per 100,000, 0.19 %) in 2016 to 17,745 (232 per 100,000, 0.23 %%) in 2020 (Ptrend<0.0001). Annual in-hospital mortality increased from 570 (2.8 %) in 2016 to 803 (3.9 %) in 2020 (Ptrend = 0.001) while amputations increased from 1084 (33.2 %) in 2016 to 1995 (44.6 %) in 2020 (Ptrend<0.001). Mean LOS increased from 5.1 (SD 2.7) days in 2016 to 6.5 (SD 0.9) days in 2020 (Ptrend = 0.002). The mean THC for CLI increased from $50,873 to $69,262 in 2020 (Ptrend<0.001). The endovascular revascularization rates decreased from 11.5 % (525 cases) in 2016 to 10.7 % (635 cases) in 2020 (Ptrend = 0.025). Surgical revascularization rates also increased from 4.9 % (225 cases) in 2016 to 10.4 % (600 cases) in 2020 (Ptrend = 0.041).

CONCLUSION

Hospitalization and outcomes for CLI worsened among young adults during the study period. There is an urgent need to enhance surveillance for risk factors of PAD in this age group.

Development and psychometric validation of the hospitalized patients' expectations for treatment scale-clinician version

Objective

Patient safety management systems in general hospitals require a comprehensive tool for assessing the expectations of inpatients across different wards. This study aimed to develop and psychometrically validate a new scale, the hospitalized patients' expectations for treatment scale-clinician version (HOPE-C), to meet this requirement.

Methods

We interviewed 35 experts and 10 inpatients while developing the HOPE-C scale. The scale was initially designed with three dimensions: clinicians' expectations regarding doctor-patient communication, clinicians' expectations regarding treatment outcome, and clinicians' expectations regarding disease management. We recruited 200 inpatients from a general hospital in China. At the same time, 51 clinicians were assigned to the enrolled patients who completed the HOPE-C to examine the reliability, validity, and psychometric characteristics of the questionnaire. We applied item analysis, assessed construct validity, evaluated internal consistency, and conducted a test-retest reliability analysis over 7 days.

Results

Both exploratory and confirmatory analyses supported a 2-dimensional structure, comprising doctor-patient communication expectations and treatment outcome expectations, with favorable model fit parameters (root mean square residual [RMR] = 0.042, root mean square error of approximation [RMSEA] = 0.049, comparative fit index [CFI] = 0.989, Tucker-Lewis index [TLI] = 0.984). Item analysis demonstrated appropriate item design (r = 0.744-0.961). The scale exhibited strong internal consistency, with Cronbach's α values of 0.884, 0.816, and 0.840 for the overall scale, the doctor-patient communication expectation subscale, and the treatment outcome expectation subscale, respectively. The 7-day test-retest reliability was 0.996 (p < 0.001).

Conclusion

Our findings suggest that the HOPE-C is a reliable and valid assessment tool for measuring the expectations of inpatients in general hospitals. It effectively identifies patients' expectations concerning doctor-patient communication and treatment outcomes.

Prognostic Value of Hospital Frailty Risk Score and Clinical Outcomes in Patients Undergoing Revascularization for Critical Limb-Threatening Ischemia

Background The impact of medical record-based frailty assessment on clinical outcomes in patients undergoing revascularization for critical limb-threatening ischemia (CLTI) is unknown. Methods and Results This study included patients with CLTI aged ≥18 years from the nationwide readmissions database 2016 to 2018 who underwent endovascular revascularization (ER) or surgical revascularization (SR). The hospital frailty risk score, a previously validated International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) claims-based score, was used to categorize patients into low- (<5), intermediate- (5-15), and high-risk (>15) frailty categories. Primary outcomes were in-hospital mortality and major amputation at 6 months. A total of 64 338 patients were identified who underwent ER (82.3%) or SR (17.7%) for CLTI. The mean (SD) age of the cohort was 69.3 (11.8) years, and 63% of patients were male. This study found a nonlinear association between hospital frailty risk score and in-hospital mortality and 6-month major amputation. In both ER and SR cohorts, the intermediate- and high-risk groups were associated with a significantly higher risk of in-hospital mortality (high-risk group: ER: odds ratio [OR], 7.2 [95% CI, 4.4-11.6], P<0.001; SR: OR, 28.6 [95% CI, 3.4-237.6], P=0.002) and major amputation at 6 months (high-risk group: ER: hazard ratio [HR], 1.6 [95% CI, 1.5-1.7], P<0.001; SR: HR, 1.7 [95% CI, 1.4-2.2], P<0.001) compared with the low-risk group. Conclusions The hospital frailty risk score, generated from the medical record, can identify frailty and predict in-hospital mortality and 6-month major amputation in patients undergoing ER or SR for CLTI. Further studies are needed to assess if this score can be incorporated into clinical decision-making in patients undergoing revascularization for CLTI.

Risk of amputation under diuretics in patients with or at risk of lower extremity arterial disease: A systematic review and meta-analysis

BACKGROUND

Recently, increased risk of amputation under sodium glucose cotransporter-2 inhibitors has been debated. Similar concerns have been raised with other "traditional" diuretics, more particularly in patients with or at risk of lower extremity arterial disease (LEAD).

AIM

To collect all available data on any potential risk of amputation associated with diuretics in patients with or at risk of LEAD. Additionally, we looked for other limb-related events in these patients.

METHODS

We searched in PubMed, Embase and Scopus databases up to February 2021 for references, using peripheral or lower extremity arterial disease, diuretics and amputation keywords, excluding case reports, experimental animal studies and non-English reports.

RESULTS

Among the 1376 hits identified in the databases, six studies were finally included in this review, including one cross-sectional and five longitudinal studies (total of 47,612 participants). One study was limited to thiazide diuretics, one focused on loop diuretics and the remainder mixed all diuretics. All studies reported a significant association between diuretic use and amputation risk in patients with or at high risk of LEAD. Despite some limitations in several studies, the meta-analysis showed an increased risk of amputation associated with diuretics (odds ratio: 1.75, 95% confidence interval: 1.53-1.99; P<0.001). Beyond amputation, patients with or at risk of LEAD under diuretics appeared to be at increased risk of other lower limb events, mostly in the presence of other comorbidities, including diabetes.

CONCLUSIONS

Although the amount of data in the literature is scarce, this first systematic review and meta-analysis favours an increased risk of amputation in patients with or at risk of LEAD under diuretics. Further prospective studies must be conducted to provide a better understanding of the mechanisms. Meanwhile, the use of diuretics in these patients should be parsimonious, considering alternatives whenever possible.

Endovascular Therapy in an "All-Comers" Risk Group for Chronic Limb-Threatening Ischemia Demonstrates Safety and Efficacy When Compared with the Established Performance Criteria Proposed by the Society for Vascular Surgery

BACKGROUND

The aim of this study was to describe the applicability of the Society for Vascular Surgery (SVS) objective performance goals (OPGs) as a tool to evaluate results in the context of endovascular management of noncomplex and complex patients (i.e., end stage renal disease/history of prosthetic conduit) with chronic limb-threatening ischemia (CLTI).

METHODS

Patients diagnosed with CLTI undergoing endovascular procedures from March 2016 to April 2017 were included, and medical records were examined. Patients were categorized as OPG risk (OPGR) and non-OPG risk (nOPGR) groups in accordance with the SVS performance criteria. We compared clinical events between the two groups and then further to the SVS OPGs. Thirty-day outcomes (safety) were major amputation (AMP), major adverse limb events (MALEs), and major adverse cardiovascular events (MACEs), and 1-year outcomes (efficacy) were limb salvage, MALE + 30-day perioperative death (MALE + POD), and survival. Mortality was demonstrated using Kaplan-Meier analysis.

RESULTS

A total of 72 patients were included (OPGR = 58.3% vs. nOPGR = 41.7%). Mean follow-up was 20 months (range, 1-40 months). Retrograde pedal access was used in 65.2% of patients. The overall AMP rate was 2.7% (OPGR = 4.7%, nOPGR = 0%, P = 0.225, vs. SVS OPG<3%), MALE was 4.1% (OPGR = 7.1%, nOPGR = 0%, P = 0.135, vs. SVS OPG<8%), and MACE was 6.9% (OPGR = 2.3%, nOPGR = 13.3%, P = 0.071, vs. SVS OPG<8%). The limb salvage was 90.3% (OPGR = 88%, nOPGR = 93.3%, P = 0.46, vs. SVS OPG>84%), MALE + POD was 76.4% (OPGR = 78.6%, nOPGR = 73.4%, P = 0.606, vs. SVS OPG>71%), and survival was 77.7% (OPGR = 83.3%, nOPGR = 70%, P = 0.18, vs. SVS OPG>80%).

CONCLUSIONS

The SVS OPGs set appropriate safety and efficacy standards as a bar for new technologies. In this series, endovascular therapy in all-comers exceeded the safety and efficacy endpoints proposed by the limited risk OPG panel.

Risk factors analysis of thromboembolectomy for acute thromboembolic lower extremity ischemia in native arteries

BACKGROUND

Aim of this study is to report the results of thromboembolectomy (ThEmb) for acute thromboembolic lower limb ischemia (ATLI) in native arteries and to create a predictive score for amputation-free survival (AFS) at 30 days.

METHODS

It is a single center, retrospective analysis of a four years period. All patients had ThEmb: adjunctive procedures included femoral and/or popliteal endarterectomy in 30 (18.3%) cases, PTA-stent in 24 (14.6%), and femoral endarterectomy plus PTA-stent in 12 (7.3%). Fasciotomies were performed in 6 (3.6%) patients. Predictors of AFS identified on univariate screen (inclusion threshold, P<.20) were included in a multivariable model. The resulting significant predictors were assigned an integer score to stratify patients into risk groups.

RESULTS

Authors analyzed 164 limbs in 164 patients. Mean age was 80±10 years (range, 40-99). In-hospital mortality was 9.8% (N.=16); AFS at 30 days was 84.7% (N.=139). The anatomic level (iliac vs. femoropopliteal vs. infrapopliteal) of the occlusion did not affect AFS (P=.326). Multivariable analysis identified six significant predictors of AFS at 30 days: age >85 (P=0.050), chronic obstructive pulmonary disease (P=0.008), chronic renal insufficiency (P=0.019), late (>6 hours) onset (P=0.004), the presence of major neurologic deficit (P=0.023), and an increased (>800IU/L) level of creatine phosphokinase (P=0.001). An integer score generated two risk groups (low-risk 0-2 [70.1% of cohort], and high-risk ≥3 [29.9% of cohort]): stratification of the patients according to risk category yielded significantly different AFS at 30 days (low-risk 5.2% vs. high-risk 38.8%, P<0.0001).

CONCLUSIONS

Among patients selected to undergo ThEmb for ATLI in native arteries, this risk score identified a group of patients with a 40% chance of death or major amputation at 30 days. The score can help to optimize the operative strategy, but further prospective validation is needed.

Building a Critical Limb Ischemia Program

OPINION STATEMENT

The need to develop highly qualified, multidisciplinary critical limb ischemia (CLI) programs has gained significant momentum. Due to the systemic nature of the disease, patients with CLI are inherently medically complex and often present with multiple comorbidities. Successful care for these patients depends on community screening, early referral, accurate diagnosis, risk stratification, risk factor modification, invasive and non-invasive treatment strategies, and appropriate surveillance. Patients with CLI are often treated by multiple subspecialists-often lacking a unified team which could lead to inefficiencies and redundancy. Establishing an effective critical limb ischemia program relies on the joint efforts of multiple physician specialists, nurses, technicians, wound care specialists, researchers, and administrators who together form an integrated network that is easily accessible to the patient. This article will focus on the various modalities needed to build an advanced critical limb ischemia program, while addressing the challenges facing the medical community in caring for this population.

Limits of infrainguinal bypass surgery for critical leg ischemia in high-risk patients (Finnvasc score 3-4)

BACKGROUND

The aim of the present study was to compare the early- and midterm outcomes after infrainguinal bypass surgery in the treatment of low- and high-risk patients with critical limb ischemia (CLI) (Finnvasc score 0-2 and 3-4, respectively), and to evaluate limits of infrainguinal bypass surgery in treatment of the latter group.

METHODS

Two hundred seventy-four infrainguinal bypass procedures performed in 218 patients were retrospectively reviewed. The Finnvasc score (range: 0-4) was calculated by assigning one point to each of four preoperative risk factors, that is, coronary artery disease, diabetes, urgency of the procedure, and gangrene. Major outcome end points were survival, limb salvage, and amputation-free survival.

RESULTS

Among 274 infrainguinal bypass procedures performed for CLI, 92 procedures (33.6%) were performed in patients with Finnvasc score 3-4. They had significantly lower leg salvage (at 3-year follow-up, 53.7 vs. 70.6%; log-rank: p = 0.004), survival (at 3-year follow-up, 49.7 vs. 69.7%; log-rank: p < 0.0001), and amputation-free survival (at 3-year follow-up, 27.7 vs. 53.1%; log-rank: p < 0.0001) compared with patients with Finnvasc score 0-2. Patients with Finnvasc score 3-4 and a preoperative serum creatinine level of >150 μmol/L had 1-year amputation-free survival of 12.5%, whereas patients with lower level of creatinine had 1-year amputation-free survival of 53.1% (p = 0.028).

CONCLUSIONS

Infrainguinal bypass revascularization in CLI patients who present with Finnvasc score 3-4 can be considered at higher risk of poor intermediate outcome in terms of survival, leg salvage, and amputation-free survival. Poor outcome is particularly expected in patients with Finnvasc score 3-4 and renal failure. In this subgroup of patients, primary amputation should be considered.

[Role of duplex ultrasound for lower limb artery, abdominal aorta, and carotid artery surgery follow-up]

Long-term post-surgery follow-up is an essential part of the surgical and medical care for vascular surgery patients with peripheral arterial disease. Close collaboration with the patient's primary care physician is essential. In addition to close surveillance of the outcome after vascular surgery, follow-up includes an assessment and appropriate treatment of cardiovascular risk factors. Duplex ultrasound is a safe and noninvasive surveillance method, which should be performed by an experimented physician. We summarize the specific features of duplex ultrasound examinations after arterial surgery of the carotid arteries, the abdominal aorta and the lower limbs, and propose a surveillance schedule.