Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

Andrew T O Nickinson; Jivka Dimitrova; John S M Houghton; Lauren Rate; Svetlana Dubkova; Hannah Lines; Laura J Gray; Sarah Nduwayo; Tanya J Payne; Rob D Sayers; Robert S M Davies

doi:10.1016/j.ejvs.2020.12.007

Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

Eur J Vasc Endovasc Surg. 2021 Apr;61(4):612-619. doi: 10.1016/j.ejvs.2020.12.007. Epub 2021 Feb 12.

Affiliations

¹ Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK. Electronic address: an290@leicester.ac.uk.
² Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK.
³ Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK.
⁴ Department of Health Sciences, University of Leicester, Leicester, UK.
⁵ Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.

PMID: 33583708
DOI: 10.1016/j.ejvs.2020.12.007

Abstract

Objective: Vascular limb salvage services are recommended by the Global Vascular Guidelines to help improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study reports the 12 month outcomes for an outpatient based vascular limb salvage (VaLS) clinic.

Methods: An analysis of a prospectively maintained database, involving all consecutive patients diagnosed with CLTI within the VaLS clinic from February 2018-February 2019, was undertaken. Data were compared with two comparator cohorts, identified from coding data: 1) patients managed prior to the clinic, between May 2017 and February 2018 (Pre-Clinic [PC]); and 2) patients managed outside of clinic, between February 2018 and February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan-Meier plots and adjusted Cox's proportional hazard models (aHR) were used to compare outcomes.

Results: Five hundred and sixty-six patients (VaLS 158, AP 173, PC 235) were included (median age 74 years). Patients managed within the VaLS cohort were statistically significantly more likely to be free from major amputation (90.5%) compared with both the AP (82.1%, aHR 0.52, 95% confidence interval [CI] 0.28 - 0.98, p = .041) and the PC (80.0%; aHR 0.50, 95% CI 0.28 - 0.91, p = .022) cohorts at 12 months, after adjustment for age, disease severity, and presence of diabetes.

Conclusion: This study supports the recommendations of the Global Vascular Guidelines that vascular limb salvage clinics may improve the rate of major amputation. Furthermore, the study provides a reproducible service model that delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer term outcomes.

Keywords: Amputation; Critical pathways; Health care quality; Limb salvage; Peripheral arterial disease; Peripheral vascular disease; Time to treatment; United Kingdom; Vascular surgical procedures; access; and evaluation.

Publication types

Comparative Study

MeSH terms

Aged
Aged, 80 and over
Amputation, Surgical*
Chronic Disease
Databases, Factual
Endovascular Procedures* / adverse effects
England
Female
Humans
Ischemia / diagnostic imaging
Ischemia / physiopathology
Ischemia / therapy*
Limb Salvage* / adverse effects
Male
Middle Aged
Peripheral Arterial Disease / diagnostic imaging
Peripheral Arterial Disease / physiopathology
Peripheral Arterial Disease / therapy*
Program Evaluation
Quality Improvement*
Quality Indicators, Health Care*
Retrospective Studies
Risk Assessment
Risk Factors
Time Factors
Treatment Outcome