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Increased awareness of CLI necessary
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HOLLYWOOD, Fla. — Increased awareness of peripheral artery disease and critical limb ischemia is essential to ensuring better management of the disease, according to a speaker at the International Symposium on Endovascular Therapy.
“In the United States right now, undiagnosed and poorly managed PAD, as well as a lack of recognition and aggressive treatment of its risk factors — diabetes, hypertension, hyperlipidemia, kidney disease, tobacco abuse — contribute to fuel the CLI epidemic,” Jihad A. Mustapha, MD, FACC, FSCAI, of Metro Health Hospital in Grand Rapids, Michigan, said during a presentation. “It affects about 1 million Medicare patients per year, with an estimated annual cost of more than $3 billion.”
According to data from CMS, approximately 120,000 amputations are performed annually, and at about $800,000, the estimated lifetime health care costs for a patient who has undergone amputation can be considerable, he noted. Using these data, the expected lifetime cost for all of these patients totals $95 billion.
“When we combine all of these costs, we can see the tremendous burden it places on our government,” he said.
The clinical burden also cannot be underestimated, according to Mustapha. After an initial extremity amputation due to vascular causes, 27% of patients have at least one re-amputation within 1 year, and 40% progress to a higher level of limb loss within 1 year of an initial toe, foot or ankle amputation — a rate that increases to 62% with comorbid diabetes. Moreover, 55% of those with PAD will have the other limb amputated within 2 or 3 years. In addition to the actual limb loss, this postprocedure transition places a significant burden on patients and their families, he noted.
The mortality rate after amputation is also extremely high and increases with time and ascending level of amputation. Compared with cancer rates, 5-year survival is significantly greater for breast cancer (89.7%) and colon cancer (65.1%) than CLI, which hovers around 17%, according to Mustapha. Raising awareness of breast and colon cancer has led to increased funding and research and decreased mortality, he said, noting that doing the same for CLI would potentially have the same benefit.
Although health care resources targeting CLI have grown, major lower extremity amputation remains common, with the intensity of vascular care for patients with CLI varying regionally. Mustapha noted that regions with the most intensive vascular care have the lowest rates of amputation. Advanced endovascular and more aggressive treatments exist in certain centers, but this is not the case across the board.
“CLI tends to be a moving target,” Mustapha said. “This is something we have to be aware of and try to find some form of standard approach so everyone can receive the same care. … We need to be really aggressive in revascularization and preventing amputation.”
The crux of the problem, according to Mustapha, is a lack of awareness and knowledge, especially in certain areas. PAD often goes undiagnosed because some patients initially do not experience symptoms. However, by the time the disease becomes symptomatic and reaches the CLI stage, the number of treatment options and the number of physicians who can treat the disease are limited.
“We must catch it early and treat early,” he said. “Amputation is too often a first-line therapy, and this is something we’re all working toward improving and reducing.”
In light of considerable burden of the disease, it is imperative that physicians and researchers find a solution, Mustapha noted.
“A concerted effort can create change,” he said. “We need to amplify awareness of PAD and its progressive nature; increase clinical cooperation and information sharing in the management of PAD; and create programs that simultaneously advance awareness, management and treatments.”
Additionally, a multidisciplinary approach and post-intervention management are extremely important, according to Mustapha. Partnerships between clinicians, hospital patients and industry can also have an immediate effect, with the goal of preventing complications and death due to CLI. – by Melissa Foster
Reference:
Mustapha J. Concurrent Session VII: Deep dive on below the knee therapy and CLI. Presented at: International Symposium on Endovascular Therapy; Feb. 4-8, 2017; Hollywood, Fla.
Disclosure: Mustapha reports consulting for Abbott Vascular, Bard Peripheral Vascular, Boston Scientific, Cardiovascular Systems Inc., Cook Medical, Medtronic, Spectranetics and Terumo.