Successful treatment of CLI requires collaboration, awareness

Michael R. Jaff

HOLLYWOOD, Fla. — Patients with critical limb ischemia face enormous challenges, and the medical community must work closely together to improve their lives via the best known treatments, a speaker said at the International Symposium on Endovascular Therapy (ISET).

“We make decisions about the treatments for these patients without even thinking about which ones necessarily work best and last the longest,” Michael R. Jaff, DO, MSVM, FSCAI, FACP, FACC, president of Newton-Wellesley Hospital, professor of medicine at Harvard Medical School and a member of the Cardiology Today and Cardiology Today’s Intervention Editorial Boards, said. “But our patients are begging us to figure this out.”

Patients with CLI have high risk for limb loss, including contralateral limb loss, and mortality and other morbidities; often require urgent revascularization even though as many as half are never offered it; need optimal adjuvant medical therapy; and must have their wounds and infections managed carefully, he said.

Fortunately, the LIBERTY 360° study is in progress to evaluate any FDA-approved technology for the treatment of claudication and CLI; it is one of the few studies that has Rutherford class 6 patients, who have severe CLI, he said.

“Most people believe that [Rutherford class 6] patients are too far gone, and that amputation is the most appropriate first-line treatment,” Jaff said. “That turned out not to be the case. If you have critical limb ischemia, by the time you present to a doctor, the likelihood of you already having an amputation is extraordinarily high, especially in the Rutherford 6 class. These are people who are really disadvantaged and warrant aggressive revascularization.”

Other research found that one in five patients with CLI is readmitted within 30 days, which Jaff said is not a big surprise given that many of them have comorbidities such as HF, CAD, diabetes and chronic kidney disease. Although that is bad from a cost perspective, he said, “the truth of the matter is, it may actually be a good thing. These might be the patients we are continuing to be aggressive about managing, following and re-treating so they have optimal outcomes.”

Vascular disease accounts for more than 50% of limb amputations, which were associated with $8.3 billion in hospital costs in 2009 and occur at a higher rate in black and Hispanic patients vs. white patients, Jaff said. Also of note, he said, is that secondary health effects of amputation include increased odds of obesity, hypertension, CVD mortality and falls.

In one study, “less than half of patients who presented with critical limb ischemia actually had an attempted revascularization in the year prior to their amputation,” Jaff said. “That’s just absurd, since we know the cornerstone of therapy for CLI is improvement in perfusion through revascularization.”

Spreading this message is one of the missions of the CLI Global Society, a multidisciplinary, nonprofit, membership-based medical society with a commitment to raise public, patient and health professional awareness of CLI and prevent unnecessary amputations and related deaths, said Jaff, one of the society’s founding members.

“If we’re going to do this, we all need to work together to get involved to help save the lives and limbs of our patients,” he said. – by Erik Swain

Reference:

Jaff MR. Deep Dive Session 4: CLI and Complex PAD. Presented at: the International Symposium on Endovascular Therapy (ISET); Feb. 3-7, 2018; Hollywood, Fla.

Disclosure: Jaff reports he is a consultant for Abbott Vascular, the American Orthotics and Prosthetics Association, Boston Scientific, Cordis/Cardinal Health, Medtronic, Micell and Philips/Volcano, holds equity in Embolitech, Janacare, PQ Bypass, Primacea, Sano V, Vactronix, Vascular Therapies and Venarum, and serves on the executive committee of the BEST-CLI trial.