Acute and chronic limb ischaemia

Chronic limb ischaemia presents over time. The most common cause of chronic ischaemia is peripheral arterial disease (PAD). Risk factors for the development of PAD may be modifiable or non-modifiable (age, gender, ethnicity and family history). Intermittent claudication, the most common presenting symptom, may have a relatively benign prognosis in many cases, whereas critical limb ischaemia (CLI) refers to disease progression with threatened limb loss, and requires intervention. In contrast, acute limb ischaemia occurs suddenly, commonly due to thrombosis, embolization or trauma (including iatrogenic causes), and may also be limb threatening, requiring urgent investigation and intervention in order to reduce risks of limb loss

Outcomes of Sub-threshold Abdominal Aortic Aneurysms Undergoing Surveillance in Patients Aged 85 Years or Over

Objective Despite an increasing elderly population there is limited evidence regarding the surveillance and management of small abdominal aortic aneurysms (AAAs) in octogenarians. This study investigated outcomes of patients aged ≥85 years undergoing AAA surveillance to identify whether discontinuation of surveillance might be safe. Methods This was a retrospective cohort study of all patients aged 85 years undergoing surveillance with a small (30–54 mm) AAA between January 2007 and November 2017. Patients were stratified depending on aneurysm diameter at index ( 50 mm). A threshold of 55 mm was used to decide intervention in all patients. Subsequent management of threshold aneurysms, aneurysm related and all cause mortality were also collected. Results One hundred and one patients were included (88 male, mean diameter at index 45 mm, median follow up 56.0 months). The majority of patients (72.3%) undergoing surveillance had not reached threshold at the end of follow up. Only one patient in the 50 mm groups, respectively (p 50 mm index group). Conclusion The present data suggests that discontinuation of aneurysm surveillance in patients aged 85 years with aneurysms < 40 mm might be safe. In patients with a larger aneurysm or those approaching threshold, early assessment of fitness for surgery may prevent unnecessary surveillance. The decision to treat aneurysms reaching threshold is complex but is appropriate in selected patients

The Relationship Between Obesity and Amputation-free Survival in Patients Undergoing Lower-limb Revascularisation for Chronic Limb-threatening Ischaemia: A Retrospective Cohort Study

BackgroundThe obesity paradox is a well-documented phenomenon in cardiovascular disease, however it remains poorly understood. We aimed to investigate the relationship between body mass (as measured by body mass index [BMI]) and 1-year amputation-free survival (AFS) for patients undergoing lower limb revascularisation for chronic limb-threatening ischaemia (CLTI).MethodsA retrospective analysis was undertaken of all consecutive patients undergoing lower limb revascularisation for CLTI at the Leicester Vascular Institute between February 2018–19. Baseline demographics and outcomes were collected using electronic records. BMI was stratified using the World Health Organization criteria. One-year AFS (composite of major amputation/death) was the primary outcome. Kaplan-Meier survival analysis and adjusted Cox's proportional hazard models were used to compare groups to patients of normal mass.ResultsOne-hundred and ninety patients were included. Overall, no difference was identified in 1-year AFS across all groups (pooled P = 0.335). Compared to patients with normal BMI (n = 66), obese patients (n = 43) had a significantly lower adjusted combined risk of amputation/death (aHR 0.39, 95% CI 0.16–0.92, P = 0.032), however no significant differences were observed for overweight (aHR 0.89, 95% CI 0.47–1.70, P = 0.741), morbidly obese (aHR 1.15, 95% CI 0.41–3.20, P = 0.797) and underweight individuals (aHR 1.86, 95% CI 0.56–6.20, P = 0.314).ConclusionsIn the context of CLTI, obesity is potentially associated with favourable amputation-free survival at 1 year, compared to normal body mass. The results of this study support the notion of an obesity paradox existing within CLTI and question whether current guidance on weight management requires a more patient-specific approach.</div

A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

Objectives Patients presenting with chronic limb threatening ischaemia (CLTI) and diabetic foot ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern exists regarding late presentation and delayed management contributing to increased amputation rates. Despite multiple guidelines existing on the management of both conditions, there is currently no accepted timeframe in which to enact specialist care and treatment. This systematic review aims to investigate potential time delays in the identification, referral and management of both CLTI and DFU. Methods A systematic review, conforming to the Preferred Reporting Items for Systematic Review of Meta-Analysis (PRISMA) statement standards, was performed searching MEDLINE, Embase, The Cochrane Library and CINAHL from inception to 14 13 th November 2018. All English language qualitative and quantitative articles investigating or reporting the identification, causes and outcomes of time delays within ‘high income’ countries (annual gross domestic product per person >$15,000) were included. Data were extracted independently by the investigators. Given the clinical cross-over, both conditions were investigated together. A study protocol was designed and registered at the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42018115286). Results A total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and 1,388 healthcare professionals were included. Twenty-three articles focussed predominantly on DFU. Considerable heterogeneity was noted and only 12 articles were deemed of high quality. Only 4 articles defined a ‘delay’ however this was not consistent between studies. Median times from symptom onset to specialist healthcare assessment ranged from 15 to 126 days with subsequent median times from assessment to treatment ranging from 1 to 91 days. A number of patient and healthcare factors were consistently reported as potentially causative including, poor patient symptom recognition, inaccurate healthcare assessment and difficulties in accessing specialist services. Twenty articles reported outcomes of delays, namely rates of major amputation, ulcer healing and all-cause mortality. Although results were heterogeneous, they elude to delays being associated with detrimental outcomes for patients. Conclusions Time delays exist in all aspects of the management pathway, which are in some cases considerable in length. The causes of these are complex but reflect poor patient health-seeking behaviours, inaccurate healthcare assessment and barriers to referral and treatment within the care pathway. The adoption of standardised limits for referral and treatment times, exploration of missed opportunities for diagnosis and investigation of novel strategies for providing specialist care are required to help reduce delays.</div

Frailty factors and outcomes in vascular surgery patients: a systematic review and meta-analysis

Objective To describe and critique tools used to assess frailty in vascular surgery patients, and investigate its associations with patient factors and outcomes. Background Increasing evidence shows negative impacts of frailty on outcomes in surgical patients, but little investigation of its associations with patient factors has been undertaken. Methods Systematic review and meta-analysis of studies reporting frailty in vascular surgery patients (PROSPERO registration: CRD42018116253) searching Medline, Embase, CINAHL, PsycINFO and Scopus. Quality of studies was assessed using Newcastle Ottawa scores (NOS) and quality of evidence using GRADE criteria. Associations of frailty with patient factors were investigated by difference in means (MD) or expressed as risk ratios (RR), and associations with outcomes expressed as odds ratios (OR) or hazard ratios (HR). Data were pooled using random effects models. Results Fifty-three studies were included in the review and only 8 (15%) were both good quality (NOS ≥7) and used a well-validated frailty measure. Eighteen studies (62,976 patients) provided data for the meta-analysis. Frailty was associated with increased age (MD 4.05 years; 95% confidence interval [CI] 3.35, 4.75), female sex (RR 1.32; 95%CI 1.14, 1.54), and lower body-mass index (MD -1.81; 95%CI -2.94, -0.68). Frailty was associated with 30-day mortality (adjusted [A]OR 2.77; 95%CI 2.01-3.81), post-operative complications (AOR 2.16; 95%CI 1.55, 3.02) and long-term mortality (HR 1.85; 95%CI 1.31, 2.62). Sarcopenia was not associated with any outcomes. Conclusion Frailty, but not sarcopenia, is associated with worse outcomes in vascular surgery patients. Well-validated frailty assessment tools should be preferred clinically, and in future research.</div

Leg Ischaemia Management collaboration (LIMb): study protocol for a prospective cohort study at a single UK centre

Introduction Severe limb ischaemia (SLI) is the end-stage of peripheral arterial occlusive disease where the viability of the limb is threatened. Around 25% of patients with SLI will ultimately require a major lower limb amputation which has a substantial adverse impact on quality of life. A newly established rapid-access vascular limb salvage clinic and modern revascularisation techniques may reduce amputation rate. The aim of this study is to investigate the 12-month amputation rate in a contemporary cohort of patients and compare this to a historical cohort. Secondary aims are to investigate the use of frailty and cognitive assessments, and cardiac MRI in risk-stratifying patients with SLI undergoing intervention and establish a biobank for future biomarker analyses. Methods & analysis This single-centre prospective cohort study will recruit patients aged 18-110 years presenting with SLI. Those undergoing intervention will be eligible to undergo additional venepuncture (for biomarker analysis) and/or cardiac MRI. Those aged ≥65 years and undergoing intervention will also be eligible to undergo additional frailty and cognitive assessments. Follow-up will be at 12 and 24 months and subsequently via data-linkage with NHS digital to 10 years post-recruitment. Those undergoing cardiac MRI and/or frailty assessments will receive additional follow-up during the first 12 months to investigate for peri-operative myocardial infarction and frailty related outcomes, respectively. A sample size of 420 patients will be required to detect a 10% reduction in amputation rate in comparison to a similar sized historical cohort, with 90% power and 5% type-I error rate. Statistical analysis of this comparison will be by adjusted and unadjusted logistic regression analyses. Ethics & dissemination Ethical approval for this study has been granted by the UK National Research Ethics Service (19/LO/0132). Results will be disseminated to participants, via scientific meetings, peerreviewed medical journals and social media. Study registration ClinicalTrials.gov [NCT04027244