Lack of Guideline Adherence in Peripheral Artery Disease and Critical Limb Ischemia | Journal Scan

Study Questions:

What is the contemporary state of treatment and associated outcomes for patients with peripheral artery disease (PAD) and critical limb ischemia (CLI)?


Using the largest German public health insurer’s database, all diagnostic and procedural data (inpatient and outpatient) were obtained from a cohort of 41,882 patients hospitalized with PAD between 2009 and 2011. Follow-up data were collected through 2013. Patients were categorized by Rutherford class (1-3, 4, 5, and 6) based on ICD code, and associated PAD and CLI risk factors were assessed. Patients with Rutherford classes 4-6 were categorized as having CLI.


Classic PAD and CLI risk factor prevalence such as hypertension, dyslipidemia, and smoking declined slightly with higher Rutherford categories (each p < 0.001), whereas diabetes, chronic kidney disease, and chronic heart failure increased slightly (each p < 0.001). Angiography and revascularization were performed less often in advanced PAD (Rutherford class 5 and 6) compared to Rutherford class 4 patients (each p < 0.001). In-hospital amputations increased continuously from 0.5% of all Rutherford class 1-3 patients, to 42% of all Rutherford class 6 patients. Of 4,298 amputated patients with CLI, 37% had not received any angiography or revascularization during any hospitalization in the prior 24 months. Kaplan-Meier projected 4-year mortality risk was 18.9%, 37.7%, 52.2%, and 63.5% for Rutherford class 1-3, 4, 5, and 6, respectively. Projected 4-year amputation risk was 4.6%, 12.1%, 35.3%, and 67.3% for Rutherford class 1-3, 4, 5, and 6, respectively. Increasing Rutherford class was associated with adjusted risk of death, amputation, myocardial infarction, and stroke.


The authors concluded that current outcomes are poor for patients with PAD and CLI. They also concluded that CLI patients receive significantly fewer angiography and revascularization procedures than PAD patients, despite overwhelming evidence for a reduction of limb loss with revascularization.


Using a large database of PAD and CLI patients, the authors demonstrate that higher-risk PAD patients (particularly those with CLI) were increasingly likely to undergo amputation despite 37% of these patients not undergoing angiography or an attempt at revascularization in the prior 24 months. Importantly, it does not appear that the authors were able to capture the use of computed tomography- or magnetic resonance imaging-based angiography, which are commonly used to assess the arterial perfusion in PAD patients. The authors suggest that patients with CLI may not be receiving potential limb-saving procedures and instead are advancing directly to amputation. This study suggests that many patients do not undergo the American College of Cardiology/American Heart Association guideline-recommended attempt at revascularization prior to amputation. Clinicians would be advised to collaborate closely with skilled endovascular physicians and vascular surgeons to identify all potential therapeutic options for their patients with PAD and CLI.

Clinical Topics: Cardiac Surgery, Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Smoking

Keywords: Peripheral Arterial Disease, Amputation, Angiography, Myocardial Revascularization, Diabetes Mellitus, Dyslipidemias, Heart Failure, Hospitalization, Myocardial Infarction, Mortality, Renal Insufficiency, Chronic, Risk Factors, Smoking, Stroke, Insurance Carriers

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