A single center’s 15-year experience with palliative limb care for chronic limb threatening ischemia in frail patients
| Autor: | Christian Bianchi, Sheela T. Patel, Ahmed M. Abou-Zamzam, Ben C. Caputo, Theodore Teruya, Courtney Kohne, Agustin Sibona, Beatriz Leong, Allen Murga |
|---|---|
| Rok vydání: | 2022 |
| Předmět: |
Chronic Limb-Threatening Ischemia
Male medicine.medical_specialty Time Factors Palliative care Frail Elderly medicine.medical_treatment Single Center Revascularization Patient Readmission Risk Assessment Amputation Surgical Quality of life Risk Factors medicine Humans Registries Aged Retrospective Studies Veterans Aged 80 and over Wound Healing Frailty business.industry Incidence (epidemiology) Palliative Care Recovery of Function Middle Aged Limb Salvage Natural history Functional Status Treatment Outcome Amputation Emergency medicine Cohort Female Surgery Cardiology and Cardiovascular Medicine business |
| Zdroj: | Journal of Vascular Surgery. 75:1014-1020.e1 |
| ISSN: | 0741-5214 |
| Popis: | Our institution's multidisciplinary Prevention of Amputation in Veterans Everywhere (PAVE) program allocates veterans with critical limb threatening ischemia (CLTI) to immediate revascularization, conservative care, primary amputation, or palliative limb care according to previously reported criteria. These four groups align with the approaches outlined by the global guidelines for the management of CLTI. In the present study, we have delineated the natural history of the palliative limb care group of patients and quantified the procedural risks and outcomes.Veterans prospectively enrolled into the palliative limb cohort of our PAVE program from January 2005 to January 2020 were analyzed. The primary outcome was mortality. The secondary outcomes included overall and limb-related readmissions, limb loss, and wound healing. The clinical frailty scale (CFS) score was calculated, and the 5-year expected mortality was estimated using the Veterans Affairs Quality Enhancement Research Initiative tool. Regression analysis was performed to establish associations among the following variables: mortality, wound, ischemia, and foot infection (WIfI) score, CFS score, overall admissions, and limb-related admissions.The PAVE program enrolled 1158 limbs during 15 years. Of the 1158 limbs, 157 (13.5%) in 145 patients were allocated to the palliative limb care group. The overall mortality of the group was 88.2% (median interval, 3.5 months; range, 0-91 months). Of the 128 patients who had died, 64 (50%) had died within 3 months of enrollment. The predicted 5-year mortality for the group was 66%. The average CFS score for the group was 6.2, denoting persons moderately to severely frail. Using the CFS score, 106 patients were considered frail and 39 were considered not frail. No differences were found in mortality between the frail and nonfrail patients. However, a statistically significant difference was found in early (3 months) mortality (56.2% vs 37.5%; P = .032). The 30-day limb-related readmission rate was 4.7%. Eventual major amputation was necessary for 18 limbs (11.5%). Wound healing occurred in 30 patients (20.6%). Regression analysis demonstrated no association between the CFS score and mortality (r = 0.55; P = .159) or between the WIfI score and mortality (r = 0.0165; P = .98). However, a significant association was found between the WIfI score and limb-related admissions (r = 0.97; P .001).Frail patients with CLTI had high early mortality and a low risk of limb-related complications. They also had a low incidence of deferred primary amputation or limb-related readmissions. In our cohort, the vast majority of patients had died within a few months of enrollment without requiring an amputation. A comprehensive approach to the treatment of CLTI patients should include a palliative limb care option because a significant proportion of these patients will have limited survival and can potentially avoid unnecessary surgery and major amputation. |
| Databáze: | OpenAIRE |
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