Endovascular Therapy for Critical Limb Ischemia Better Than Surgery on Several Counts

Patients with critical limb ischemia (CLI) have better immediate outcomes with endovascular therapy than open surgery, an observational study suggests. Compared with those who had surgery, endovascular patients were less likely to die, spent fewer days in the hospital, and had care that was less expensive overall.

“That’s a big deal to us,” said senior author Mehdi H. Shishehbor, DO, MPh, PhD, in an interview with TCTMD. “These patients have significant morbidity and mortality, and they rarely get much attention.”

Shishehbor, lead author Shikhar Agarwal, MD, MPH, and coauthor Karan Sud, MD (Cleveland Clinic, Cleveland, OH), used data from the Nationwide Inpatient Sample to look at trends in hospitalization for CLI among 642,433 patients from 2003 to 2011. Their findings were published online today in the Journal of the American College of Cardiology.  

The overall rate of CLI admissions was fairly constant throughout the study period. However, PAD-related admissions increased. In more than half of CLI patients admitted, the main reason for admission was primary CLI. Additionally, the percentage of patients with cardiovascular risk factors (hypertension, obesity, diabetes, chronic kidney disease, and prior amputation) increased steadily during the study period. At the same time, there was a steady decline in rates of in-hospital death and limb amputation above the ankle (major amputation) for CLI patients.

From 2003 to 2011, the percentage of patients treated surgically decreased from 13.9% to 8.8%, while that of patients treated with endovascular therapy more than doubled from 5.1% to 11.0%.

Hospitalization and Cost-Utilization Benefit

When patients were compared by treatment strategy, rates of major amputation were similar between the surgery and endovascular therapy groups, but the latter group had lower rates of in-hospital mortality, length of stay and hospitalization costs.

The study authors note that most prior studies of population trends have included patients with PAD and CLI, setting their results apart since they are specific to those with CLI.

“These are very different populations,” Shishehbor said. That the rate of admissions for CLI had remained constant is somewhat surprising, he said. Taken together with the increase in PAD-related admissions, the findings hint at better early detection and management of PAD, which may have contributed to stabilizing CLI rates.

The study also confirms previous data, including outcomes disparity with regard to socioeconomic status and geography, Shishehbor said. “We also confirmed that revascularization was one of the most important treatments that you could offer these patients. If they did not get it, they really did bad.”

Shishehbor added that while more confirmation is needed, “it’s hard to imagine that the increase in the number of endovascular procedures has not had an impact on the declining rates of amputation as we saw in this study.”

Importantly, he noted, the findings likely underestimate the rates of mortality, amputation and cost savings since sicker patients with more comorbidities are more likely to be referred for endovascular therapy.

“Overall, what I think our study shows is that the field is doing a good job in reducing the rates of amputation in these patients,” Shishehbor concluded.

• Agarwal S, Sud K, Shishehbor MH. Nationwide trends of hospital admission and outcomes among adults with critical limb ischemia from 2003 to 2011. J Am Coll Cardiol. 2016;Epub ahead of print. 

Disclosures:

• The researchers report no relevant conflicts of interest. 

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• OLIVE Registry: Endovascular Therapy Outcomes for CLI ‘Reasonable’ at 3 Years
• Endovascular Therapy Promising for Critical Limb Ischemia