In the Journals

Long-term survival, costs comparable for CLI revascularization techniques; amputation risk lower with endovascular strategy

Jihad A. Mustapha

Rates of major amputation following revascularization were lower after the endovascular technique. Compared with either revascularization strategy, patients with CLI who underwent primary major amputation had decreased survival time, increased risk for subsequent major amputation and greater costs.

“The findings show that we should always attempt revascularization,” Jihad A. Mustapha, MD, interventional cardiologist and critical limb ischemia specialist at Advanced Cardiac and Vascular Amputation Prevention Centers in Grand Rapids, Michigan, told Cardiology Today’s Intervention. “Patients with both endovascular or surgical revascularization do much better than those undergoing primary amputation.”

Medicare beneficiaries

Researchers analyzed administrated claims data from 72,199 patients (mean age, 74 years; 52% men) who were Medicare beneficiaries and were diagnosed with first-time CLI in 2011. Follow-up was conducted through September 2015. Other data that were analyzed include demographic patient data, comorbidities, geographic data and clinical presentation.

Major treatment for CLI was categorized as surgical revascularization, endovascular revascularization or major amputation, which was defined as above the ankle.

The main clinical outcomes of interest were major amputation and survival during 4 years of follow-up.

During follow-up, the survival rate was 46% and the rate of freedom from major amputation was 87%.

Of the 9,942 patients who were propensity-score matched, 66% had gangrene, 8% had rest pain and 26% had an ulcer. Survival with endovascular revascularization was 38%, 40% for surgical revascularization and 23% with major amputation. The survival rate was higher when each revascularization approach was compared with major amputation (P < .001).

The major amputation rate during follow-up was 9.6% for surgical revascularization, 6.5% for endovascular revascularization and 10.6% for primary major amputation (P for all < .001).

Cost after revascularization

When comparing each revascularization approach with major amputation, the cost per patient-year after adjusting for follow-up duration was $49,200 for surgical revascularization, $49,700 for endovascular revascularization and $55,700 for major amputation (P < .001).

“I cannot stress enough how important it is to ‘just do something,’” Mustapha said in an interview. “The study has shown that both endovascular revascularization and surgical revascularization provide almost equal success for the same patients who were told they have no options. This is justification to ‘just do something!’ Every patient who has been told they need an amputation should ask for a second opinion and ensure that they have received an adequate diagnostic workup and evaluation by a vascular specialist.”

“It is important to emphasize that urgent revascularization is imperative to improve outcomes in these patients,” Javier A. Valle, MD, MSCS, and Stephen W. Waldo, MD, of the division of cardiology at University of Colorado in Aurora and division of cardiology at VA Eastern Colorado Health Care System in Denver, wrote in a related editorial. “Prior data suggest that a substantial number of individuals with CLI do not undergo any revascularization attempt before amputation, confirmed in the present analysis. Education about the importance of revascularization for limb salvage among primary care practitioners and ancillary services, like podiatry, are critical to improve outcomes for this condition.” – by Darlene Dobkowski

For more information:

Jihad A. Mustapha, MD, can be reached at Advanced Cardiac and Vascular Amputation Prevention Centers, 1525 E. Beltline Ave. NE, Suite 101, Grand Rapids, MI 49525; email: jihadmustapha@aol.com; Twitter: @Mustapja.

Disclosures: Mustapha reports he consults with Abbott Vascular, Bard Peripheral Vascular, Boston Scientific, Cardiovascular Systems, Cook Medical, Medtronic, Spectranetics and Terumo. Waldo reports he received research support to the Denver Research Institute from Abiomed, Cardiovascular Systems and Merck Pharmaceuticals. Valle reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Jihad A. Mustapha
Patients with critical limb ischemia who underwent endovascular or surgical revascularization had comparable rates of long-term survival and overall costs, according to a study published in the Journal of the American Heart Association.

Rates of major amputation following revascularization were lower after the endovascular technique. Compared with either revascularization strategy, patients with CLI who underwent primary major amputation had decreased survival time, increased risk for subsequent major amputation and greater costs.

“The findings show that we should always attempt revascularization,” Jihad A. Mustapha, MD, interventional cardiologist and critical limb ischemia specialist at Advanced Cardiac and Vascular Amputation Prevention Centers in Grand Rapids, Michigan, told Cardiology Today’s Intervention. “Patients with both endovascular or surgical revascularization do much better than those undergoing primary amputation.”

Medicare beneficiaries

Researchers analyzed administrated claims data from 72,199 patients (mean age, 74 years; 52% men) who were Medicare beneficiaries and were diagnosed with first-time CLI in 2011. Follow-up was conducted through September 2015. Other data that were analyzed include demographic patient data, comorbidities, geographic data and clinical presentation.

Major treatment for CLI was categorized as surgical revascularization, endovascular revascularization or major amputation, which was defined as above the ankle.

The main clinical outcomes of interest were major amputation and survival during 4 years of follow-up.

During follow-up, the survival rate was 46% and the rate of freedom from major amputation was 87%.

Of the 9,942 patients who were propensity-score matched, 66% had gangrene, 8% had rest pain and 26% had an ulcer. Survival with endovascular revascularization was 38%, 40% for surgical revascularization and 23% with major amputation. The survival rate was higher when each revascularization approach was compared with major amputation (P < .001).

The major amputation rate during follow-up was 9.6% for surgical revascularization, 6.5% for endovascular revascularization and 10.6% for primary major amputation (P for all < .001).

Cost after revascularization

When comparing each revascularization approach with major amputation, the cost per patient-year after adjusting for follow-up duration was $49,200 for surgical revascularization, $49,700 for endovascular revascularization and $55,700 for major amputation (P < .001).

“I cannot stress enough how important it is to ‘just do something,’” Mustapha said in an interview. “The study has shown that both endovascular revascularization and surgical revascularization provide almost equal success for the same patients who were told they have no options. This is justification to ‘just do something!’ Every patient who has been told they need an amputation should ask for a second opinion and ensure that they have received an adequate diagnostic workup and evaluation by a vascular specialist.”

“It is important to emphasize that urgent revascularization is imperative to improve outcomes in these patients,” Javier A. Valle, MD, MSCS, and Stephen W. Waldo, MD, of the division of cardiology at University of Colorado in Aurora and division of cardiology at VA Eastern Colorado Health Care System in Denver, wrote in a related editorial. “Prior data suggest that a substantial number of individuals with CLI do not undergo any revascularization attempt before amputation, confirmed in the present analysis. Education about the importance of revascularization for limb salvage among primary care practitioners and ancillary services, like podiatry, are critical to improve outcomes for this condition.” – by Darlene Dobkowski

For more information:

Jihad A. Mustapha, MD, can be reached at Advanced Cardiac and Vascular Amputation Prevention Centers, 1525 E. Beltline Ave. NE, Suite 101, Grand Rapids, MI 49525; email: jihadmustapha@aol.com; Twitter: @Mustapja.

Disclosures: Mustapha reports he consults with Abbott Vascular, Bard Peripheral Vascular, Boston Scientific, Cardiovascular Systems, Cook Medical, Medtronic, Spectranetics and Terumo. Waldo reports he received research support to the Denver Research Institute from Abiomed, Cardiovascular Systems and Merck Pharmaceuticals. Valle reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.