The Current State of Critical Limb Ischemia

Farber, Alik; Eberhardt, Robert T.

doi:10.1001/jamasurg.2016.2018

Cited by 244 publications

(170 citation statements)

References 74 publications

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“…If patients are too frail for surgery or have a high likelihood of complications or vascular deterioration too great to correct, community‐based programmes offering SET and/or IPC or NMES offer accessible, low cost options to improve patient‐centred outcomes, alone, or in combination with ER therapy for avoiding amputation‐related disability and mortality …”

Section: Discussionmentioning

confidence: 99%

Peripheral arterial disease: Scoping review of patient‐centred outcomes

Bolton

2019

International Wound Journal

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Peripheral arterial disease (PAD) impairs patients' quality of life (QOL), walking and ulcer healing, increasing patient pain, costs, and risks of amputation or mortality. A literature appraisal described PAD treatment capacity to improve validated patient-centred outcomes in controlled clinical studies. The PUBMED database was searched from 1 January 1970 to 21 June 2018, for original and derivative controlled clinical trial references addressing MeSH terms for 'ischemia' AND 'leg ulcer'. Non-ischemic ulcer treatment references were excluded. Frequencies of improved (P < .05) outcomes were reported. Eighty-eight studies on 4153 patients were summarized. Walking, pain or QOL improved mainly for interventions administered before PAD became severe. Amputation incidence, pain and ulcer healing were more frequently reported in those with severe PAD. Independent of PAD severity, patients experienced more likely improved walking, QOL, or pain reduction in response to structured walking interventions or those increasing calf muscle activity. Those with more severe PAD were more likely to report amputation reduction, mainly in response to invasive interventions. Those with PAD experienced more consistently improved patient-centred outcomes if they received multidisciplinary PAD management with supervised walking or calf muscle activity, with more likely amputation risk reduced for those with more severe PAD. Key Messages• Peripheral arterial disease (PAD) progresses in severity from impaired walking and quality of life (QOL) through increasing likelihood of pain, ulceration, gangrene, amputation, or death and magnifies clinical, economic, and patient burdens of venous insufficiency or diabetes • improving PAD-related patient-centred outcomes requires consistent early, effective PAD diagnosis and effective treatment to improve lower limb perfusionAbbreviations: ABI, ankle-to-brachial systolic blood pressure index (ratio), optimally performed using handheld Doppler ultrasound; ALU, arterial leg ulcers; CLI, critical limb ischaemia; DAPT, dual antiplatelet therapy, for example, aspirin plus low molecular weight heparin; DFU, diabetic foot ulcers; ER, endovascular revascularisation; HBO, hyperbaric oxygen; IC, intermittent claudication; IPC, intermittent pneumatic compression of the calf muscle; MLU, mixed aetiology leg ulcers complicated with peripheral arterial disease; NMES, neuromuscular electrical stimulation sufficient to cause contraction of the calf muscle; PAD, peripheral arterial disease; PPG, photoplethysmography a technique for measuring venous emptying; QOL, quality of life; RCT, randomised clinical trial; SET, structured exercise therapy supervised by a professional; SOC, standard of care; TcPO 2 , transcutaneous partial pressure of oxygen; VLU, venous leg ulcer.

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Section: Discussionmentioning

confidence: 99%

Peripheral arterial disease: Scoping review of patient‐centred outcomes

Bolton

2019

International Wound Journal

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“…9 Our results endorse these findings in patients with CLI. Because of high amputation rates (35%e67%) 3,8,30 in CLI, a valid QoL outcome and HS is important in vascular amputees. In our study, vascular amputees (with a one-year mortality of 35%) showed statistically significant improvement in the physical QoL domain at one-year follow-up (survey response 67%, n ¼ 20).…”

Section: Discussionmentioning

confidence: 99%

“…7 Due to a lack of randomized controlled trials, no recommendation for therapy can be made in CLI patients. 7,8 Consequently, a patient-oriented appraisal of treatment is becoming increasingly important. 9e11 The importance of the patient-reported outcome measure, QoL, is broadly recognized.…”

Section: Introductionmentioning

confidence: 99%

Quality of Life and not Health Status Improves After Major Amputation in the Elderly Critical Limb Ischaemia Patient

Peters

Vries

Lodder

et al. 2019

European Journal of Vascular and Endovascular Surgery

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WHAT DOES THIS STUDY/REVIEW ADD TO THE EXISTING LITERATURE AND HOW WILL IT INFLUENCE FUTURE CLINICAL PRACTICEIn elderly patients with critical limb ischaemia (CLI), guidelines about the definition of quality of life and the instruments that measure quality of life are sparse. Often quality of life is confused with health status. This study provides evidence that there is a discrepancy between quality of life and health status in elderly CLI patients undergoing major amputation. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. We advocate the use of distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, in future research.Objectives: A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an 'objective' evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation. Methods: Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not.The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL.The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up. Results: Two-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p ¼ 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p ¼ 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; À2.23),p ¼ 0.003). Conclusions: There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when as...

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“…In fact, a 2‐year mortality rate of greater than 40% has been reported rendering CLI as one of the most lethal manifestations of cardiovascular disease. An estimated 1% of the adult population has CLI, and with the aging population and increases in cardiovascular comorbidities, continued rises in CLI incidence are anticipated …”

Section: Introductionmentioning

confidence: 99%

“…An estimated 1% of the adult population has CLI, and with the aging population and increases in cardiovascular comorbidities, continued rises in CLI incidence are anticipated. 2 Despite the poor outcomes associated with CLI, its detection and treatment remain suboptimal. PAD underdiagnosis is common, 3 and in part is related to provider knowledge gaps and fragmented follow-up care.…”

Section: Introductionmentioning

confidence: 99%