Decision-Making in Critical Limb Ischemia: A Markov Simulation

Abstract

Background Critical limb ischemia (CLI) is a feared complication of peripheral vascular disease that often requires surgical management and may require amputation of the affected limb. Objective To use a decision model to inform clinical management for a 63-year-old woman with CLI and multiple medical comorbidities, including advanced heart failure and diabetes. Methods Markov decision model evaluating four strategies: amputation, surgical bypass, endovascular therapy (e.g. stent or revascularization), and medical management. We measured the impact of parameter uncertainty using 1-way, 2-way, and multi-way sensitivity analyses. Results In the base case, endovascular therapy yielded similar discounted quality-adjusted life-months (26.50 QALMs) compared to surgical bypass (26.34 QALMs). Both endovascular and surgical therapies were superior to amputation (18.83 QALMs), and medical management (11.08 QALMs). This finding was robust to a wide range of peri-procedural mortality weights, and was most sensitive to long-term mortality associated with endovascular and surgical therapies. Limitations Utility weights were not stratified by patient comorbidities; nonetheless, our conclusion was robust to a range of utility weight values. Conclusions For a patient with CLI, endovascular therapy and surgical bypass provided comparable clinical outcomes. However, this finding was sensitive to long-term mortality rates associated with each procedure. Both endovascular and surgical therapies were superior to amputation or medical management in a range of scenarios.