Peripheral Arterial Disease and Critical Limb Ischemia

Study Questions:

What are the outcomes of peripheral arterial disease (PAD) in its distinct stages with special regard to endovascular and surgical revascularization?


From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41,882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21,197), 4 (n = 5,353), 5 (n = 6,916), and 6 (n = 8,416). Events during follow-up were displayed by Kaplan-Meier models; differences between the distinct Rutherford subgroups were compared by the log-rank test. The predictive value of baseline parameters concerning long-term outcomes was tested by multivariable Cox regression models; results were displayed as hazard ratios and 95% confidence intervals.


The proportion of patients with classic risk factors such as hypertension, dyslipidemia, and smoking declined with higher Rutherford categories (each p < 0.001), while diabetes, chronic kidney disease, and chronic heart failure increased (each p < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each p < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each p < 0.001). Among 4,298 amputated patients with chronic limb ischemia (CLI), 37% had not received any angiography or revascularization neither during index hospitalization nor in the 24 months before. During follow-up (mean 1,144 days), 7,825 patients were amputated and 10,880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each p < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1 days, 15.2 ± 13.8 days, and 22.1 ± 20.3 days; p < 0.001) and mean case costs (3,662 ± 3,186 €, 5,316 ± 6,139 €, 6,021 ± 4,892 €, and 8,461 ± 8,515 €; p < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €).


The authors concluded that current outcomes remain poor in PAD, especially in CLI.


This observational study reports that regardless of recent advances in PAD treatment, current outcomes remain poor, especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations. It seems reasonable based on available data that vascular diagnostics and revascularization (endovascular or surgical, depending on what is best suitable) be more appropriately recommended in all patients with CLI or a risk for amputation.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension, Smoking

Keywords: Amputation, Angiography, Diabetes Mellitus, Dyslipidemias, Endovascular Procedures, Heart Failure, Hypertension, Myocardial Infarction, Myocardial Revascularization, Peripheral Arterial Disease, Renal Insufficiency, Chronic, Risk Factors, Smoking, Stroke

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