Before major amputation, most patients with CLI do not have revascularization
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Among patients with critical limb ischemia, nearly two-thirds did not have revascularization or angiography before undergoing major amputation, researchers reported at VIVA 21.
Eric A. Secemsky, MD, MSc, RPVI, FACC, FSCAI, FSVM, director of vascular intervention at Beth Israel Deaconess Medical Center, director of vascular research at the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and assistant professor of medicine at Harvard Medical School, and colleagues conducted a retrospective analysis of 7,904 Medicare fee-for-service beneficiaries with CLI aged at least 66 years (mean age, 77 years; 61% men; 68% white; 35% with low income) who underwent major amputation in 2017.
“There are 2 million critical limb ischemia patients in the U.S.; 25% require an amputation within a year of diagnosis and 50% have 5-year mortality post-amputation,” Secemsky said during a presentation. “We know there are plenty of disparities that exist in the care of these patients with critical limb ischemia. It’s our imperative to really understand the factors associated with these disparities, and what the role of the pre-amputation care has on long-term outcomes.”
The primary outcome was whether patients received high-intensity, medium-intensity or low-intensity vascular interventions before their major amputation. Patients in the high-intensity group had revascularization. Patients in the medium-intensity group had angiography. Patients in the low-intensity group had neither.
Overall, 31% of patients had high-intensity intervention, 6% had medium-intensity intervention and 63% had low-intensity intervention prior to their amputation, Secemsky said.
In addition, 69% of patients did not have revascularization in the 1 year before major amputation, 92% of those not revascularized also did not have an angiogram, 26% had a minor amputation and/or wound debridement in the year before major amputation and 46% received an above-the-knee amputation, he said.
Factors associated with low-intensity intervention included male sex, low-income status and being treated at a safety-net hospital, according to the researchers.
Two-year mortality after major amputation occurred in 23% of the low-intensity group, 20% of the medium-intensity group and 19% of the high-intensity group, Secemsky said, noting that factors associated with death included prior MI, renal dysfunction, end-stage renal disease and treatment at a safety-net hospital (P < .05 for all).
“Other markers include that being male is protective,” Secemsky said. “Even though men were more likely to get low-intensity care, they still did better than women. This is a persistent issue for us in delivering peripheral vascular care to our patients.”
At 12 months, 40% of the high-intensity group were readmitted to the hospital, compared with 50% of the medium-intensity group and 48% of the low-intensity group, he said.
“Only a minority of patients with critical limb ischemia had any attempt at revascularization prior to major amputation,” Secemsky said during the presentation. “What we do before amputation makes a difference. Intensity of vascular care was associated with important post-amputation outcomes, including a greater risk of death if you got low intensity of care, as well as greater risk of readmission. We need to figure out a way to reduce these disparities, improve the care of our patients and make an impact on long-term outcomes.”
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Secemsky EA, et al. Late-Breaking Clinical Trials. Presented at: VIVA 21; Oct. 4-7, 2021; Las Vegas (hybrid meeting).
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