Advertisement

Current Cardiology Reports

, 20:74 | Cite as

Preventing Major Amputations in Patients with Critical Limb Ischemia

  • Eric W. Rudofker
  • Shea E. Hogan
  • Ehrin J. Armstrong
Peripheral Vascular Disease (CJ Cooper and R Gupta, Section Editors)
  • 78 Downloads
Part of the following topical collections:
  1. Topical Collection on Peripheral Vascular Disease

Abstract

Purpose of Review

This review summarizes the risks of lower extremity amputation associated with critical limb ischemia (CLI) and discusses current therapies that can prevent amputation in CLI.

Recent Findings

CLI remains an under-recognized condition associated with high rates of major amputation and disparities in care. Optimal medical therapy can reduce the risk of major adverse cardiovascular and limb events, but revascularization combined with close wound care remains the cornerstone of amputation prevention. Endovascular revascularization has become more common over time and has been associated with a reduction in amputation rates. Ongoing clinical trials will help inform best practices for revascularization strategies and techniques.

Summary

Vascular care is inconsistent across the USA, with significant variation in access to care revascularization rates and rates of major amputation. Major amputation can be prevented in patients with CLI when optimal medical therapy, lifestyle modification, and revascularization are provided in a multidisciplinary setting.

Keywords

Critical limb ischemia Amputation Prevention Revascularization Management Disparities 

Notes

Compliance with Ethical Standards

Conflict of Interest

Eric W. Rudofker and Shea E. Hogan declare that they have no conflict of interest.

Ehrin J. Armstrong reports being a consultant for Abbott Vascular, Boston Scientific, Cardiovascular Systems, Medtronic, and Philips.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance

  1. 1.
    Dua A, Lee CJ. Epidemiology of peripheral arterial disease and critical limb ischemia. Tech Vasc Interv Radiol. 2016;19(2):91–5.  https://doi.org/10.1053/j.tvir.2016.04.001.CrossRefPubMedGoogle Scholar
  2. 2.
    Nehler MR, Duval S, Diao L, Annex BH, Hiatt WR, Rogers K, et al. Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population. J Vasc Surg. 2014;60(3):686–95.e2.  https://doi.org/10.1016/j.jvs.2014.03.290.CrossRefPubMedGoogle Scholar
  3. 3.
    •• 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(16):1901–13.  https://doi.org/10.1016/j.jacc.2016.02.040. Landmark study demonstrating reduced amputation rates and increasing use of endovascular strategies. CrossRefPubMedGoogle Scholar
  4. 4.
    Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33(Suppl 1):S1–75.  https://doi.org/10.1016/j.ejvs.2006.09.024. CrossRefPubMedGoogle Scholar
  5. 5.
    Swaminathan A, Vemulapalli S, Patel MR, Jones WS. Lower extremity amputation in peripheral artery disease: improving patient outcomes. Vasc Health Risk Manag. 2014;10:417–24.  https://doi.org/10.2147/VHRM.S50588.PubMedPubMedCentralGoogle Scholar
  6. 6.
    Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermott MM, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–40.  https://doi.org/10.1016/S0140-6736(13)61249-0.CrossRefPubMedGoogle Scholar
  7. 7•.
    . Shishehbor MH, White CJ, Gray BH, Menard MT, Lookstein R, Rosenfield K, et al. Critical limb ischemia: an expert statement. J Am Coll Cardiol. 2016;68(18):2002–15.  https://doi.org/10.1016/j.jacc.2016.04.071. Excellent overview of treatment options for critical limb ischemia. CrossRefPubMedGoogle Scholar
  8. 8.
    • Teraa M, Conte MS, Moll FL, Verhaar MC. Critical limb ischemia: current trends and future directions. J Am Heart Assoc. 2016;5(2):e002938.  https://doi.org/10.1161/JAHA.115.002938. Timely discussion of emerging therapies. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mills JL, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220–34.e1-2.  https://doi.org/10.1016/j.jvs.2013.08.003.CrossRefPubMedGoogle Scholar
  10. 10.
    Rollins KE, Jackson D, Coughlin PA. Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia. Br J Surg. 2013;100(8):1002–8.  https://doi.org/10.1002/bjs.9127.CrossRefPubMedGoogle Scholar
  11. 11.
    Hardman RL, Jazaeri O, Yi J, Smith M, Gupta R. Overview of classification systems in peripheral artery disease. Semin Interv Radiol. 2014;31(4):378–88.  https://doi.org/10.1055/s-0034-1393976.CrossRefGoogle Scholar
  12. 12.
    Mills JL. The application of the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification to stratify amputation risk. J Vasc Surg. 2017;65(3):591–3.  https://doi.org/10.1016/j.jvs.2016.12.090.CrossRefPubMedGoogle Scholar
  13. 13.
    •• Farber A, Eberhardt RT. The current state of critical limb ischemia: a systematic review. JAMA Surg. 2016;151(11):1070–7.  https://doi.org/10.1001/jamasurg.2016.2018. Excellent literature summary of evidence basis for critical limb ischemia treatment. CrossRefPubMedGoogle Scholar
  14. 14.
    •• Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(12):e726–e79.  https://doi.org/10.1161/CIR.0000000000000471. Updated guidelines include decision-making strategies in CLI. CrossRefPubMedGoogle Scholar
  15. 15.
    Armstrong EJ, Wu J, Singh GD, Dawson DL, Pevec WC, Amsterdam EA, et al. Smoking cessation is associated with decreased mortality and improved amputation-free survival among patients with symptomatic peripheral artery disease. J Vasc Surg. 2014;60(6):1565–71.  https://doi.org/10.1016/j.jvs.2014.08.064.CrossRefPubMedGoogle Scholar
  16. 16.
    Chung J, Timaran DA, Modrall JG, Ahn C, Timaran CH, Kirkwood ML, et al. Optimal medical therapy predicts amputation-free survival in chronic critical limb ischemia. J Vasc Surg. 2013;58(4):972–80.  https://doi.org/10.1016/j.jvs.2013.03.050.CrossRefPubMedGoogle Scholar
  17. 17.
    Foley TR, Waldo SW, Armstrong EJ. Antithrombotic therapy in peripheral artery disease. Vasc Med. 2016;21(2):156–69.  https://doi.org/10.1177/1358863X15622987.CrossRefPubMedGoogle Scholar
  18. 18.
    Bonaca MP, Creager MA, Olin J, Scirica BM, Gilchrist IC, Murphy SA, et al. Peripheral revascularization in patients with peripheral artery disease with vorapaxar: insights from the TRA 2P-TIMI 50 trial. JACC Cardiovasc Interv. 2016;9(20):2157–64.  https://doi.org/10.1016/j.jcin.2016.07.034. CrossRefPubMedGoogle Scholar
  19. 19.
    Anand SS, Caron F, Eikelboom JW, Bosch J, Dyal L, Aboyans V, et al. Major adverse limb events in lower extremity peripheral artery disease: COMPASS trial. J Am Coll Cardiol. 2018;  https://doi.org/10.1016/j.jacc.2018.03.008.
  20. 20.
    Anand SS, Bosch J, Eikelboom JW, Connolly SJ, Diaz R, Widimsky P, et al. Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017;391:219–29.  https://doi.org/10.1016/S0140-6736(17)32409-1. CrossRefGoogle Scholar
  21. 21.
    Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366(9501):1925–34.  https://doi.org/10.1016/S0140-6736(05)67704-5.CrossRefPubMedGoogle Scholar
  22. 22.
    • Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010;51(5 Suppl):5S–17S.  https://doi.org/10.1016/j.jvs.2010.01.073. The only randomzied trial of surgical vs. endovascular revascularization in CLI. CrossRefPubMedGoogle Scholar
  23. 23.
    Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, et al. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg. 2011;54(5):e32–58.  https://doi.org/10.1016/j.jvs.2011.09.001.CrossRefPubMedGoogle Scholar
  24. 24.
    Rowe VL, Lee W, Weaver FA, Etzioni D. Patterns of treatment for peripheral arterial disease in the United States: 1996–2005. J Vasc Surg. 2009;49(4):910–7.  https://doi.org/10.1016/j.jvs.2008.11.054.CrossRefPubMedGoogle Scholar
  25. 25.
    Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006;43(2):205–16.  https://doi.org/10.1016/j.jvs.2005.11.002.CrossRefPubMedGoogle Scholar
  26. 26.
    Jones WS, Patel MR, Dai D, Subherwal S, Stafford J, Calhoun S, et al. Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease: results from U.S. Medicare 2000–2008. J Am Coll Cardiol. 2012;60(21):2230–6.  https://doi.org/10.1016/j.jacc.2012.08.983. CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Katib N, Thomas SD, Lennox AF, Yang JL, Varcoe RL. An endovascular-first approach to the treatment of critical limb ischemia results in superior limb salvage rates. J Endovasc Ther. 2015;22(4):473–81.  https://doi.org/10.1177/1526602815588279.CrossRefPubMedGoogle Scholar
  28. 28.
    •• Chopra A, Azarbal AF, Jung E, Abraham CZ, Liem TK, Landry GJ, et al. Ambulation and functional outcome after major lower extremity amputation. J Vasc Surg. 2018;67(5):1521–9.  https://doi.org/10.1016/j.jvs.2017.10.051. Important study demonstrating the significant impact amputation has on subsequent ambulation. CrossRefPubMedGoogle Scholar
  29. 29.
    Moazzami K, Moazzami B, Roohi A, Nedjat S, Dolmatova E. Local intramuscular transplantation of autologous mononuclear cells for critical lower limb ischaemia. Cochrane Database Syst Rev. 2014;12:CD008347.  https://doi.org/10.1002/14651858.CD008347.pub3.Google Scholar
  30. 30.
    Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE, Weibel S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2015;6:CD004123.  https://doi.org/10.1002/14651858.CD004123.pub4.Google Scholar
  31. 31.
    Columbo JA, Davies L, Kang R, Barnes JA, Leinweber KA, Suckow BD, et al. Patient experience of recovery after major leg amputation for arterial disease. Vasc Endovasc Surg. 2018;52(4):262–8.  https://doi.org/10.1177/1538574418761984.CrossRefGoogle Scholar
  32. 32.
    Goodney PP, Travis LL, Nallamothu BK, Holman K, Suckow B, Henke PK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes. 2012;5(1):94–102.  https://doi.org/10.1161/CIRCOUTCOMES.111.962233.CrossRefPubMedGoogle Scholar
  33. 33.
    • Goodney PP, Holman K, Henke PK, Travis LL, Dimick JB, Stukel TA, Fisher ES, Birkmeyer JD Regional intensity of vascular care and lower extremity amputation rates. J Vasc Surg 2013;57(6):1471–79, 80.e1–3; discussion 9–80.  https://doi.org/10.1016/j.jvs.2012.11.068. In-depth analysis of the relationship between revascualrization and amputation rates across the US.
  34. 34.
    Soden PA, Zettervall SL, Shean KE, Vouyouka AG, Goodney PP, Mills JL, et al. Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg. 2017;66(3):810–8.  https://doi.org/10.1016/j.jvs.2017.01.061.CrossRefPubMedGoogle Scholar
  35. 35.
    O'Donnell TFX, Powell C, Deery SE, Darling JD, Hughes K, Giles KA, et al. Regional variation in racial disparities among patients with peripheral artery disease. J Vasc Surg. 2018;  https://doi.org/10.1016/j.jvs.2017.10.090.
  36. 36.
    Jones WS, Patel MR, Dai D, Vemulapalli S, Subherwal S, Stafford J, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. Am Heart J. 2013;165(5):809–15.  https://doi.org/10.1016/j.ahj.2012.12.002. 15.e1CrossRefPubMedGoogle Scholar
  37. 37.
    Vemulapalli S, Greiner MA, Jones WS, Patel MR, Hernandez AF, Curtis LH. Peripheral arterial testing before lower extremity amputation among Medicare beneficiaries, 2000 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7(1):142–50.  https://doi.org/10.1161/CIRCOUTCOMES.113.000376.CrossRefPubMedGoogle Scholar
  38. 38.
    Barshes NR, Chambers JD, Cohen J, Belkin M, Collaborators MTOHViIEMS. Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss. J Vasc Surg. 2012;56(4):1015–24.e1.  https://doi.org/10.1016/j.jvs.2012.02.069.CrossRefPubMedGoogle Scholar
  39. 39.
    Armstrong EJ, Ryan MP, Baker ER, Martinsen BJ, Kotlarz H, Gunnarsson C. Risk of major amputation or death among patients with critical limb ischemia initially treated with endovascular intervention, surgical bypass, minor amputation, or conservative management. J Med Econ. 2017;20(11):1148–54.  https://doi.org/10.1080/13696998.2017.1361961.CrossRefPubMedGoogle Scholar
  40. 40.
    Barshes NR, Kougias P, Ozaki CK, Goodney PP, Belkin M. Cost-effectiveness of revascularization for limb preservation in patients with end-stage renal disease. J Vasc Surg. 2014;60(2):369–74.e1.  https://doi.org/10.1016/j.jvs.2014.02.003.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Barshes NR, Kougias P, Ozaki CK, Pisimisis G, Bechara CF, Henson HK, et al. Cost-effectiveness of revascularization for limb preservation in patients with marginal functional status. Ann Vasc Surg. 2014;28(1):10–7.  https://doi.org/10.1016/j.avsg.2013.08.004.CrossRefPubMedGoogle Scholar
  42. 42.
    Kearns BC, Michaels JA, Stevenson MD, Thomas SM. Cost-effectiveness analysis of enhancements to angioplasty for infrainguinal arterial disease. Br J Surg. 2013;100(9):1180–8.  https://doi.org/10.1002/bjs.9195.CrossRefPubMedGoogle Scholar
  43. 43.
    Sridharan ND, Boitet A, Smith K, Noorbakhsh K, Avgerinos E, Eslami MH, et al. Cost-effectiveness analysis of drug-coated therapies in the superficial femoral artery. J Vasc Surg. 2018;67(1):343–52.  https://doi.org/10.1016/j.jvs.2017.06.112.CrossRefPubMedGoogle Scholar
  44. 44.
    Soden PA, Zettervall SL, Curran T, Vouyouka AG, Goodney PP, Mills JL, et al. Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative. J Vasc Surg. 2017;65(1):108–18.  https://doi.org/10.1016/j.jvs.2016.06.105.CrossRefPubMedGoogle Scholar
  45. 45.
    Hughes K, Seetahal S, Oyetunji T, Rose D, Greene W, Chang D, et al. Racial/ethnic disparities in amputation and revascularization: a nationwide inpatient sample study. Vasc Endovasc Surg. 2014;48(1):34–7.  https://doi.org/10.1177/1538574413510618.CrossRefGoogle Scholar
  46. 46.
    Hughes K, Boyd C, Oyetunji T, Tran D, Chang D, Rose D, et al. Racial/ethnic disparities in revascularization for limb salvage: an analysis of the National Surgical Quality Improvement Program database. Vasc Endovasc Surg. 2014;48(5–6):402–5.  https://doi.org/10.1177/1538574414543276.CrossRefGoogle Scholar
  47. 47.
    •• Arya S, Binney Z, Khakharia A, Brewster LP, Goodney P, Patzer R et al. Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease. J Am Heart Assoc. 2018;7(2).  https://doi.org/10.1161/JAHA.117.007425. Contemporary analysis of the societal factors affecting amputation rates.
  48. 48.
    Soden PA, Zettervall SL, Deery SE, Hughes K, Stoner MC, Goodney PP, et al. Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular intervention. J Vasc Surg. 2018;67(2):549–56.e3.  https://doi.org/10.1016/j.jvs.2017.06.089.CrossRefPubMedGoogle Scholar

Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018

Authors and Affiliations

  • Eric W. Rudofker
    • 1
  • Shea E. Hogan
    • 1
    • 2
  • Ehrin J. Armstrong
    • 1
    • 3
    • 4
  1. 1.University of Colorado School of MedicineAuroraUSA
  2. 2.Denver Health Medical CenterDenverUSA
  3. 3.Veterans Affairs Eastern Colorado Health Care SystemDenverUSA
  4. 4.Denver VA Medical CenterDenverUSA

Personalised recommendations