February 13, 2020
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Revascularization increased as mortality, amputation decreased in veterans with CLI

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Saket Girotra

The rates of mortality and major amputation have significantly decreased as the use of revascularization increased during the past decade in veterans with critical limb ischemia, according to a study published in Circulation: Cardiovascular Interventions.

“Patients with critical limb ischemia have advanced obstruction in their leg arteries, which puts them at a high risk of amputation,” Saket Girotra, MD, SM, assistant professor of cardiovascular medicine at the University of Iowa Carver College of Medicine in Iowa City, told Healio. “Such patients should be evaluated by vascular experts to determine if they are candidates for revascularization. Medications such as high-intensity statins are also important for lowering their cardiovascular risk.”

Amgad Mentias, MD, MSc, associate professor of internal medicine at University of Iowa Carver College of Medicine, and colleagues analyzed data from 20,938 veterans (mean age, 68 years) who were admitted to a Veterans Affairs facility for CLI between 2005 and 2014. The primary outcome was major amputation and mortality at 90 days.

The incidence of CLI decreased from 2005 to 2013 (0.3 per 1,000 enrollees to 0.24 per 1,000 enrollees; P for trend < .01).

From 2005 to 2014, there were temporal increases in the use of surgical (23.8% to 26.4%), endovascular (11.2% to 18.4%) and hybrid revascularization (6.2% to 13.1%; P for trend < .01) within 90 days of hospitalization. Prescriptions for statins also increased during this period from 47.4% to 60.9% (P for trend < .01).

At 90 days, there were significant declines in major amputation (19.8% to 12.9%) and mortality (11.8% to 9.7%) from 2005 to 2014 after adjusting for temporal trends in patient characteristics (P for trend < .01). Revascularization was linked to a lower risk for major amputation (RR = 0.23; 95% CI, 0.21-0.26) and mortality (RR = 0.45; 95% CI, 0.41-0.5) at 90 days in adjusted analyses.

Approximately half of patients who underwent amputation did not undergo an invasive vascular procedure 90 days prior.

The median revascularization rate at the facility level was 41.7% and varied more than fourfold across sites. Differences in the case mix of patients accounted for 8% of the variation for revascularization use on a facility level.

“While our findings document an overall improvement in outcomes for patients with critically blocked leg arteries, opportunities for improvement remain,” Girotra said in an interview. “We found a large proportion of patients were still not receiving recommended medications such as statins. Use of revascularization also varied across hospitals. We need to better understand the barriers due to which some patients may not receive the recommended treatment for CLI.” – by Darlene Dobkowski

For more information:

Saket Girotra, MD, SM, can be reached at saket-girotra@uiowa.edu; Twitter: @saketgirotra.

Disclosures: The authors report no relevant financial disclosures.