Preventing Major Amputations in Patients with Critical Limb Ischemia
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.
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.
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.
KeywordsCritical limb ischemia Amputation Prevention Revascularization Management Disparities
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.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major Importance
- 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
- 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•.. 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
- 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
- 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.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
- 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.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.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
- 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.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
- 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
- 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
- 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.
- 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.
- 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
- 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
- 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
- 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.•• 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.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