Trends in Hospitalization, Management, and Clinical Outcomes Among Veterans With Critical Limb Ischemia

Abstract

Background: Contemporary patterns in management and outcomes of critical limb ischemia among United States veterans are unknown. Methods: We used Veterans Health Administration data to identify patients admitted for critical limb ischemia between 2005 and 2014. We examined temporal trends in incidence, management, and outcomes. Results: A total of 20 938 veterans with critical limb ischemia were hospitalized between 2005 and 2014. Mean age was 67.8 years. Incidence decreased from 0.3 to 0.24 per 1000 persons from 2005 to 2013, P <0.01. During the study period, there was a temporal increase in use of revascularization within 90 days of hospitalization—endovascular (11.2% in 2005 to 18.4% in 2014), surgical (23.8% in 2005 to 26.4% in 2014), and hybrid (6.2% in 2005 to 13.1% in 2014, P value for trend <0.01). Statin prescriptions increased from 47.4% in 2005 to 60.9% in 2014 ( P value for trend <0.01). There was a significant decline in risk-adjusted mortality (11.8% in 2005 to 9.7% in 2014) and major amputation (19.8% in 2005 to 12.9% in 2014; P value for trend <0.01 for both) at 90 days. In adjusted analyses, revascularization was associated with a lower risk of mortality (RR, 0.45 [95% CI, 0.41–0.50]; P <0.001) and major amputation at 90 days (RR, 0.23 [95% CI, 0.21–0.26]; P <0.001). Nearly half of the patients who underwent amputation did not receive an invasive vascular procedure within the preceding 90 days. There was large site-level variation in the use of revascularization (median rate, 41.7% [interquartile range, 12.5%–53.2%]). Differences in patient case-mix explained only 8% of site-level variation in receipt of revascularization. Conclusions: Over the past decade, use of revascularization increased among veterans with critical limb ischemia, which was accompanied by a reduction in mortality and major amputation. However, opportunities to further improve care in this high-risk population still remain.

Sex Differences in Trends and In‐Hospital Outcomes Among Patients With Critical Limb Ischemia: A Nationwide Analysis

“…This could be attributed to the hesitancy for hospital admittance in patients with CLI who are women or less serious presentation among women, requiring hospitalization less often. Similar to prior CLI studies that had a predominant male representation, 21 , 22 we found that the rates of revascularization were overall low (<35%), but lower among women compared with men. This is concerning given that revascularization has been associated with lower mortality, as demonstrated in our analysis, and improved quality of life in this high‐risk population.…”

“…This is concerning given that revascularization has been associated with lower mortality, as demonstrated in our analysis, and improved quality of life in this high‐risk population. 7 , 21 This further highlights the sex‐related gaps in evidence‐based therapies that has been previously demonstrated in other cardiovascular diseases. 23 , 24 A previous analysis of the reduction of atherothrombosis for continued health (REACH) registry has shown that risk factor control is suboptimal among women compared with men with PAD.…”

“…This might be related to the rise in the rates of revascularization procedures, as well as the improvements in secondary preventative strategies including smoking cessation, statin therapy, and cardiac rehabilitation. 15 , 21 , 26 …”

“Elephant-trunk” negative pressure wound therapy for fixing artificial dermis with basic fibroblast growth factor for critical limb ischemia

“…The treatment of intractable toe ulcer with critical limb ischemia (CLI) is a challenge, because the amputation risk is approximately 40% at 1 year, and the mortality rates are over 20% at 6 months [ 1 ]. Recent study show that major amputation rate is 16.6% at 90 days, and the mortality rate is 9.9% at 90 days [ 2 ]. Total management with medication such as statins, endovascular therapy or surgical revascularization, and wound care are important [ 2 ].…”

“…Recent study show that major amputation rate is 16.6% at 90 days, and the mortality rate is 9.9% at 90 days [ 2 ]. Total management with medication such as statins, endovascular therapy or surgical revascularization, and wound care are important [ 2 ].…”