Mehdi H. Shishehbor
LAS VEGAS — Critical limb ischemia is undertreated and many patients do not receive intense therapies before amputation, an expert said at VIVA 17.
Most patients do not undergo a vascular procedure in the year before amputation, Mehdi H. Shishehbor, DO, PHD, MPH, co-chair of the Clinical Executive Committee, director of the Cardiovascular Interventional Center, and co-director of the Vascular Center at University Hospitals Harrington Heart & Vascular Institute, said during a presentation.
The rate of patients with CLI who get a vascular procedure in the year before amputation is as low as 33% in some regions, 50% in what are considered high-intensity regions and 58% in what are considered very high-intensity regions, Shishehbor, a member of the Cardiology Today’s Intervention Editorial Board, said. He noted that this rate ranges from 30% to 70% among the Medicare population.
CLI “is one of the conditions that has the highest disparities in how we treat it, in all of cardiovascular medicine,” he said.
“There are significant geographical disparities, but, more importantly in my mind, there are racial and economic disparities with this condition,” Shishehbor said. Compared with white patients, black patients “are much less likely to get revascularized, but yet have three to four times higher likelihood of undergoing major amputation,” he said.
While many treatment options for CLI exist, “we don’t have enough comparative data to decide what to use, so we use a lot of [clinical] judgment in deciding how to treat these patients,” he said. “That’s another gap, and another area of importance for patients with CLI.”
Contributing to the problem is that treating CLI is not just a matter of treating ulcers, but also infections, and often complications from diabetes, so “a whole multidisciplinary team” is required for optimal treatment.
Technology has not solved the problem either, Shishehbor said.
“After 20 years of attempting various technologies, various novel therapies, we are only left with balloon angioplasty and bypass for these patients, and we have not been able to move the needle forward in treating patients with this complex, morbid disease,” he said.
Given this, perhaps the focus should be on prevention, according to Shishehbor.
“We have to educate our patients about smoking cessation and about having a good diet,” he said. “Preventing [CLI] may save limbs and may save lives.” – by Erik Swain
Shishehbor MH. Improving CLI Care: Who, What and Why. Presented at: VIVA 17; Sept. 11-14, 2017; Las Vegas.
Disclosure: Shishehbor reports no relevant financial disclosures.