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Team approach, early intervention key to avoiding amputation in patients with CLI
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LAS VEGAS — When a patient is diagnosed with critical limb ischemia, a team approach to management and early endovascular or surgical revascularization is recommended.
Lawrence A. Garcia, MD, from the division of interventional cardiology and vascular medicine at St. Elizabeth’s Medical Center, Boston, outlined steps to identify and treat patients suspected of having critical limb ischemia (CLI) early to preserve their limbs.
Risk for progression to major amputation is as high as 40% within 6 months of diagnosis of CLI, and the majority of patients will lose a limb if revascularization is not performed, Garcia said at VIVA 16.
Previous data have demonstrated that within 1 year of diagnosis, 25% of patients with CLI will have major amputation and 20% to 25% will die, and within 5 years of diagnosis, more than 50% will die, Garcia said.
Amputation can present tremendous burdens, including inability to walk, which occurs in more than half of cases; increased risk for mortality, as less than half live longer than 3 years after amputation; and tremendous financial costs, $10 billion to $20 billion per year overall and $50,000 per family for each year of care after amputation, he said.
Avoidance of amputation is crucial, and a multidisciplinary team is helpful in that regard, according to Garcia. He noted that some institutions have integrated practice units of multidisciplinary teams that meet regularly to discuss patients with CLI, which can enable early identification of vessel attrition or failure.
“A multidisciplinary team always includes some form of interventionalist, a primary care provider, a nutritionist, a diabetologist, a podiatrist, the [infectious disease] physician, physician extenders [and] the patient’s caregivers,” he said. “It’s an approach that requires not one or two individuals at an institution but a myriad of [professionals] who provide great opportunities and education to both you and your patient when it comes to revascularization and limb salvage.”
In one study of 245 patients with CLI, diabetes and foot lesions who were cared for with an integrated team approach, only one patient underwent primary amputation, while 77% had percutaneous revascularization, 18.3% had surgical revascularization and 0.3% were managed with medical therapy. Recurrence of ulcers occurred in 1.6% of those treated with an endovascular procedure, in 0.8% of those treated with a surgical procedure and 9.3% of those treated with medical therapy, while the major amputation rates were 5.3% in those revascularized and 13.8% in those managed medically, Garcia said.
Other research has highlighted an inverse relationship between amputation rates and intensity of vascular care, he said.
The best way to stratify risk in the CLI patient population is based on wound, ischemia and foot infection, he said.
“Amputation avoidance is easiest and best when there is early education for patients and caregivers,” Garcia said. “Frequent follow-up and surveillance are without exception critical in how you should deal with patients with wounds. Early intervention, whether it be endovascular, surgical or a combination of the two, and dedicated wound care specialists are critical to salvaging [the limbs of] these patients.” – by Erik Swain
Reference:
Garcia LA. Addressing Care Questions in Critical Limb Ischemia. Presented at: VIVA 16; Sept. 18-22, 2016; Las Vegas.
Disclosure: Garcia reports receiving research funding from Abbott Vascular and Medtronic and holding equity in 480 Biomedical, Arsenal, CV Ingenuity, Essential Medical, Primacea, Scion Cardiovascular, Spirox, Syntervention and TissueGen.