Nationwide Trends Among Adults With Critical Limb Ischemia

Study Questions:

What are the trends in hospitalization of patients with critical limb ischemia (CLI) in the United States, from 2003 to 2011?


CLI and revascularization procedures were identified using International Classification of Diseases-Ninth Edition-Clinical Modification codes. In-hospital mortality and amputation were coprimary outcomes. Length of stay (LOS) and cost of hospitalization were secondary outcomes. Multivariable hierarchical logistic regression analysis with exchangeable matrix was used to determine independent predictors of in-hospital mortality in the study cohort.


The authors included a total of 642,433 admissions with CLI across 2003 to 2011. The annual rate of CLI admissions has been relatively constant across 2003 to 2011 (approximately 150 of every 100,000 people in the United States). There has been a significant reduction in the proportion of patients undergoing surgical revascularization from 13.9% in 2003 to 8.8% in 2011, while endovascular revascularization has increased from 5.1% to 11.0% during the same time period. This was accompanied by a steady reduction in the incidence of in-hospital mortality and major amputation. Compared to surgical revascularization, endovascular revascularization was associated with reduced in-hospital mortality (2.34% vs. 2.73%), mean LOS (8.7 days vs. 10.7 days), and mean cost of hospitalization ($31,679 vs. $32,485) despite similar rates of major amputation (6.5% vs. 5.7%).


The authors concluded that while CLI admission rates have remained constant from 2003 to 2011, rates of surgical revascularization have significantly declined and endovascular revascularization procedures have increased.


This study reports that there has been a reduction in the proportion of CLI patients undergoing surgical revascularization, accompanied by a corresponding increase in endovascular revascularization during the study duration. Furthermore, the endovascular approach was associated with reduced in-hospital mortality, mean LOS, and mean cost of hospitalization compared to surgical revascularization. There were gender, race, socioeconomic based, geographic, and type of hospital disparities in care of these patients, and additional research is indicated to understand the reasons for and consequences of these disparities. Such knowledge may help standardize treatment and optimize outcomes of these high-risk patients.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Aortic Surgery

Keywords: Amputation, Cardiac Surgical Procedures, Endovascular Procedures, Hospital Mortality, Incidence, Ischemia, Length of Stay, Myocardial Revascularization, Vascular Diseases

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