More use of revascularization and statins credited with better outcomes, but there is still room for improvement given a fourfold variation in revascularization rates across facilities.
Among 20,938 veterans with critical limb ischemia (CLI) hospitalized between 2005 and 2014, a multivariate analysis shows that risk-adjusted mortality at 90 days decreased significantly from 11.8% in 2005 to 9.4% in 2014 (p < 0.01 for trend).
In results published in Circulation: Cardiovascular Interventions, an even bigger change was seen with 90-day risk-adjusted rates of major amputation, which decreased from 19.8% to 12.9% over the study period (p < 0.01 for trend). (Similar findings were noted for minor amputation.)
In reviewing the nationwide data from all U.S. Department of Veterans Affairs (VA) facilities, the biggest contributing factor to the improved outcomes appeared to be revascularization to restore blood flow. These patients were 55% less likely to die and 77% less likely to undergo amputation than patients who did not undergo a revascularization procedure.
Patients with a statin prescription were 15% less likely to die (p < 0.01), but the relationship with amputation was only of borderline significance at 90 days. Although use of statins at discharge increased significantly over time, statins remained underutilized, with just over half of these CLI patients given a statin prescription within 30 days of discharge despite a Class I recommendation.
Room for Improvement
The good news might have been even better except for the sharp differences among VA hospitals in the proportion of patients undergoing revascularization procedures, which ranged from 13% to 53%, with little of the variation easily explained by differences in patient characteristics.
While the best revascularization approach (surgical or endovascular) may become clearer soon with the results of the BEST-CLI trial, endovascular techniques provide a lower-risk option for revascularization in patients with CLI. Consistent with guideline recommendations, the VA study demonstrated a significant increase in use of revascularization for CLI within 90 days over the study period, but not like that seen outside the VA system.
In the VA study, surgical bypass remained the dominant strategy (26.4%) compared with endovascular revascularization (18.4%). This is in sharp contrast to non-VA facilities. The National Inpatient Sample showed a doubling of endovascular revascularization in patients with CLI between 2003 and 2011 while rates of surgical revascularization decreased by 25% during the same period,
According to Saket Girotra, MD, senior author of the study, “All patients with CLI should be evaluated to determine if they could benefit from a procedure to restore blood flow. In addition, patients with CLI should be aggressively treated with medications, including statins, blood pressure medications if they are hypertensive, and drugs to reduce platelet stickiness in order to reduce the risk of heart attack and stroke.”
The study was supported by the Veterans Affairs Health Services Research and Development Service.
Mentias A, Qazi A, McCoy K, et al. Trends in Hospitalization, Management, and Clinical Outcomes Among Veterans With Critical Limb Ischemia. Circ Cardiovasc Interv 2020 Feb 13. https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.119.008597
Agarwal S, Sud K, Shishehbor MH. Nationwide trends of hospital admission and outcomes among critical limb ischemia patients: from 2003-2011. J Am Coll Cardiol 2016;67:1901-13. http://www.onlinejacc.org/content/67/16/1901