Critical limb ischemia (PAD) what is the natural course and outcome with interventions?
PAD affects 8 to 10 million people in America alone and is associated with a threefold to sixfold increased risk of cardiovascular morbidity and death compared with individuals without PAD.
PAD patients are at an exceptionally high risk for cardiovascular events and most eventually die of a cardiac or cerebrovascular event. Patients with CLI also have a greater risk of sustaining cardiovascular ischemic events than those with PAD alone.1 Patients with CLI represent approximately 1% of the total number of patients with PAD, with overall mortality in these patients approaching 50% at 5 years and 70% at 10 years. Immediate postoperative mortality and major limb amputation is also considerable, with a recent meta-analysis reviewing 31 studies involving bypass grafts for CLI showing rates as high as 11.6%. A study in 2009 revealed amputation rates at 1 year after lower extremity bypass of 12% for patients with CLI vs 1% for patients with claudication.The recent multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery (PREVENT III) confers, arguably, the best data for CLI patients undergoing vein bypass grafting, because it studied strictly CLI patients and included patients with advanced co-morbidities or those requiring complex operative procedures. A 2.7% perioperative mortality rate, 5.2% graft occlusion rate, 16% mortality rate at 1 year, 80% secondary patency rate at 1 year, and an 88% limb salvage rate at 1 year was observed. Well, we vascular surgeons should remember all these facts during the treatment planning!
References
1. Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, Mccann TJ, et al. Mortality Over A Period of 10 Years in Patients with Peripheral Arterial-Disease. N Engl J Med 1992;326:381-6.
2. Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag 2007;3:229-34.
3. Management of peripheral arterial disease (PAD). TransAtlantic InterSociety Consensus (TASC). Eur J Vasc Endovasc Surg 2000;19(Suppl A):Si-xxviii. S1-250.
4. Nehler MR, Peyton BD. Is revascularization and limb salvage always the treatment for critical limb ischemia? J Cardiovasc Surg 2004;45: 177-84.
5. Watelet J, Soury P, Menard JF, Plissonnier D, Peillon C, Lestrat JP, et al. Femoropopliteal bypass: In situ or reversed vein grafts? Ten-year results of a randomized prospective study. Ann Vasc Surg 1997;11: 510-9.
6. Albers M, Romiti M, Brochado-Neto FC, De Luccia N, Pereira CAB. Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia. J Vasc Surg 2006;43:498-503.
7. Goodney PP, Likosky DS, Cronenwett JL. Predicting ambulation status one year after lower extremity bypass. J Vasc Surg 2009;49:1431-9.
8. Conte MS, Bandyk DF, Clowes AW, Moneta GL, Seely L, Lorenz TJ, et al. Results of PREVENT III: a multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. J Vasc Surg 2006;43:742-50.
9. Bertele V, Roncaglioni MC, Pangrazzi J, Terzian E, Tognoni G. Clinical outcome and its predictors in 1560 patients with critical leg ischaemia. Eur J Vasc Endovasc Surg 1999;18:401-10.
10. Brahmanandam SM, Messina LM, Belkin M, Conte MS, Nguyen LL. Determinants of hospital disposition after lower extremity bypass surgery. Presented at: Vascular Annual Meeting, Scientific Program, Jun 11-14, 2009;166-7.
11. Hunink MGM, Wong JB, Donaldson MC, Meyerovitz MF, Devries J, Harrington DP. Revascularization for femoropopliteal disease—a decision and cost-effectiveness analysis. JAMA 1995;274:165-71
PAD affects 8 to 10 million people in America alone and is associated with a threefold to sixfold increased risk of cardiovascular morbidity and death compared with individuals without PAD.
PAD patients are at an exceptionally high risk for cardiovascular events and most eventually die of a cardiac or cerebrovascular event. Patients with CLI also have a greater risk of sustaining cardiovascular ischemic events than those with PAD alone.1 Patients with CLI represent approximately 1% of the total number of patients with PAD, with overall mortality in these patients approaching 50% at 5 years and 70% at 10 years. Immediate postoperative mortality and major limb amputation is also considerable, with a recent meta-analysis reviewing 31 studies involving bypass grafts for CLI showing rates as high as 11.6%. A study in 2009 revealed amputation rates at 1 year after lower extremity bypass of 12% for patients with CLI vs 1% for patients with claudication.The recent multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery (PREVENT III) confers, arguably, the best data for CLI patients undergoing vein bypass grafting, because it studied strictly CLI patients and included patients with advanced co-morbidities or those requiring complex operative procedures. A 2.7% perioperative mortality rate, 5.2% graft occlusion rate, 16% mortality rate at 1 year, 80% secondary patency rate at 1 year, and an 88% limb salvage rate at 1 year was observed. Well, we vascular surgeons should remember all these facts during the treatment planning!
References
1. Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, Mccann TJ, et al. Mortality Over A Period of 10 Years in Patients with Peripheral Arterial-Disease. N Engl J Med 1992;326:381-6.
2. Shammas NW. Epidemiology, classification, and modifiable risk factors of peripheral arterial disease. Vasc Health Risk Manag 2007;3:229-34.
3. Management of peripheral arterial disease (PAD). TransAtlantic InterSociety Consensus (TASC). Eur J Vasc Endovasc Surg 2000;19(Suppl A):Si-xxviii. S1-250.
4. Nehler MR, Peyton BD. Is revascularization and limb salvage always the treatment for critical limb ischemia? J Cardiovasc Surg 2004;45: 177-84.
5. Watelet J, Soury P, Menard JF, Plissonnier D, Peillon C, Lestrat JP, et al. Femoropopliteal bypass: In situ or reversed vein grafts? Ten-year results of a randomized prospective study. Ann Vasc Surg 1997;11: 510-9.
6. Albers M, Romiti M, Brochado-Neto FC, De Luccia N, Pereira CAB. Meta-analysis of popliteal-to-distal vein bypass grafts for critical ischemia. J Vasc Surg 2006;43:498-503.
7. Goodney PP, Likosky DS, Cronenwett JL. Predicting ambulation status one year after lower extremity bypass. J Vasc Surg 2009;49:1431-9.
8. Conte MS, Bandyk DF, Clowes AW, Moneta GL, Seely L, Lorenz TJ, et al. Results of PREVENT III: a multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. J Vasc Surg 2006;43:742-50.
9. Bertele V, Roncaglioni MC, Pangrazzi J, Terzian E, Tognoni G. Clinical outcome and its predictors in 1560 patients with critical leg ischaemia. Eur J Vasc Endovasc Surg 1999;18:401-10.
10. Brahmanandam SM, Messina LM, Belkin M, Conte MS, Nguyen LL. Determinants of hospital disposition after lower extremity bypass surgery. Presented at: Vascular Annual Meeting, Scientific Program, Jun 11-14, 2009;166-7.
11. Hunink MGM, Wong JB, Donaldson MC, Meyerovitz MF, Devries J, Harrington DP. Revascularization for femoropopliteal disease—a decision and cost-effectiveness analysis. JAMA 1995;274:165-71
