OBJECTIVE:
To look into the factors responsible for delay in presentation of Iimb ischemia patients to a vascular surgeon.  METHODS:
The prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from October 01, 2016, to August 10, 2018. Patients coming with delayed presentation of both acute and chronic limb ischemia were included. All the patients were assessed by qualified vascular surgeons. SPSS 23 was used for data analysis.  RESULTS:
Of the 55 patients, 33(60%) had acute and 22(40%) had chronic limb ischaemia. Mean age of acute cases was 44±23.72 years and it was 60±12.49 years for chronic cases. Overall, the commonest reason behind delay was non-referral by primary physician which was the case with 11(33.3%) patients in the acute group, and 13(59%) in the chronic group. The limb loss in the acute group was 20(60%) and 8(36%) in the chronic group..  CONCLUSION:
Delayed presentation of patients with limb ischaemia is mainly due to non-referral. A robust campaign needs to be launched to reduce the rate of limb loss

Rehman, Zia Ur

Riaz, Amna

Riaz, Asma

Shaikh, F A

Siddiqu, Nadeem Ahmed

Sophie, Ziad

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryFebruary 2019Why do patients with limb ischaemia present late toa vascular surgeon? A prospective cohort studyfrom the developing worldAmna RiazAga Khan University, amna.riaz@aku.eduF A. ShaikhAga Khan University, fareed.shaikh@aku.eduAsma RiazAga Khan University, asma.riaz@aku.eduZia Ur RehmanAga Khan University, ziaur.rehman@aku.eduZiad SophieAga Khan University, ziad.sophie@aku.eduSee next page for additional authorsFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surgRecommended CitationRiaz, A., Shaikh, F. A., Riaz, A., Rehman, Z., Sophie, Z., Siddiqu, N. (2019). Why do patients with limb ischaemia present late to avascular surgeon? A prospective cohort study from the developing world. The Journal of the Pakistan Medical Association, 69(Supl. 1),S3-S6.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/772AuthorsAmna Riaz, F A. Shaikh, Asma Riaz, Zia Ur Rehman, Ziad Sophie, and Nadeem Ahmed SiddiquThis article is available at eCommons@AKU: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/772IntroductionLimb ischaemia can be acute or chronic. Acute limbischaemia (ALI) threatens the viability of limb by suddencessation of blood supply.1 Worldwide its incidence is 1.5cases per 10,000 persons per year.2 Major limb amputationis one of the important complications of ALI, and the mostimportant factor responsible for this is the delay inpresentation and revascularisation.3 Despite urgentrevascularisation, the incidence proportion of majoramputation is up to 15%.4,5 On the other hand, chroniclimb ischaemia (CLI) is also a debilitating disease with aworldwide prevalence of more than 200 million people.6The incidence proportion of major amputation in CLI is26% over 4 years.7 The presentation varies fromasymptomatic to gangrene, and similarly the treatmentoptions range from conservative (medications andexercise) to complex surgical revascularisations.8 Earlierthe presentation, the less complex are the treatmentoptions.Timing of presentation followed by intervention fromonset of symptoms actually dictates the outcomes in bothtypes of limb ischaemia. For instance, in cases of ALI, thetime to intervention should be within 6 hours.9 Similarly,patients in earlier stages of peripheral arterial disease(PAD) are found to benefit more from conservativetreatment.8In Pakistan, vascular surgery is still in preliminary stageswith very limited availability of vascular surgeons at 5-6tertiary care centres in major cities only. One of thosecities is Karachi, the capital of Province Sindh. Except threetertiary care hospitals in Karachi, no other hospital hasqualified vascular surgeon in the whole province. The AgaKhan University Hospital (AKUH) is the busiest of thosethree as far as vascular service is concerned. Ourobservation is that most of our patients from both withinand outside the city present late, and subsequently theoutcomes are sub-optimal and less desirable as alsoreported by an earlier study10 which mainly auditedpractices and outcomes in trauma patients only, withoutstressing much on reasons for delayed presentation.To the best of our knowledge, there has been no studyWhy do patients with limb ischaemia present late to a vascular surgeon? A prospectivecohort study from the developing worldAmna Riaz Khan, Fareed Ahmed Shaikh, Asma Riaz, Zia-Ur-Rehman, Ziad Sophie, Nadeem Ahmed SiddiquiS-3AbstractObjective: To look into the factors responsible for delay in presentation of Iimb ischemia patientsto a vascular surgeon.Method: The prospective cohort study was conducted at the Aga Khan University Hospital, Karachi,from October 01, 2016, to August 10, 2018. Patients coming with delayed presentation of both acuteand chronic limb ischemia were included. All the patients were assessed by qualified vascular surgeons.SPSS 23 was used for data analysis.Results: Of the 55 patients, 33(60%) had acute and 22(40%) had chronic limb ischaemia. Mean ageof acute cases was 44±23.72 years and it was 60±12.49 years for chronic cases. Overall, the commonestreason behind delay was non-referral by primary physician which was the case with 11(33.3%) patientsin the acute group, and 13(59%) in the chronic group. The limb loss in the acute group was 20(60%)and 8(36%) in the chronic group.Conclusion: Delayed presentation of patients with limb ischaemia is mainly due to non-referral. Arobust campaign needs to be launched to reduce the rate of limb loss.Keywords: Delayed presentation, Factors, Limb ischaemia, Limb loss, Developing world.(JPMA 69: S-3; 2019)Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan.Correspondence: Fareed Ahmed Shaikh. e-mail: fareed.shaikh@aku.eduVol. 69, No. 01, (Suppl. 1) February 2019J Pak Med Assocwith the primary aim of finding out the causes behinddelayed presentation of patients with limb ischaemia toa vascular surgeon. The current study was planned to fillthe gap by finding out the causes for delayed presentationof patients with limb ischaemia to a vascular surgeon, andto assess the outcomes in terms of salvage or loss of limb.Subjects and MethodsThe prospective cohort study was conducted at the AgaKhan University Hospital (AKUH), Karachi, from October01, 2016, to August 10, 2018. After approval was obtainedfrom the institutional ethics review committee, ALI (GroupA) and CLI (Group B) patients with delayed presentationeither in outpatient clinic or in emergency room wereincluded. Those who came with delayed presentation ofischaemia but had already consulted a qualified vascularsurgeon or those who refused to be part of study wereexcluded. Due to paucity of evidence exact sample sizecould not be calculated and it was decided to include atleast 50 consecutive patients meeting the inclusion criteria.Delayed presentation for ALI was defined as patients whopresented after 6 hours of the onset of symptoms of acutelimb ischaemia (Rutherford Stage II).11 For CLI, delayedpresentation was defined as those with either rest painor tissue loss (Rutherford grade IV and onwards) at thetime of first presentation.11 This was considered delayedpresentation because ideally CLI patient should consulta vascular surgeon at the time of intermittent claudication.All the patients were assessed and diagnosed by qualifiedvascular surgeons.Informed consent was taken from the patients, attendantsor guardians. The patient or one of the attendants wasinterviewed during the admission process regardingreason for delayed presentation. The follow-up informationpertaining to limb loss was gathered either directly whenthe patient had amputation in the same hospital or viaphone calls when they had their procedure doneelsewhere. Data regarding baseline demographic variables,disease-related variables and reasons for delayedpresentation were collected on a pre-designed proforma.SPSS 23 was used for data entry and analysis. All categoricalvariables were expressed as frequencies and percentages,while continuous variables were mentioned as mean andstandard deviation (SD). Causes for delayed presentationin both the groups were analysed using Chi-square test.P<0.05 was considered significant.ResultsOf the 55 patients, 33(60%) had ALI and 22(40%) had CLI.In Group A, 23(70%) and in Group B 12(54%) were males.The mean age in Group A was 44±23.72 years, while inGroup B it was 60±12.49 years. Status regarding co-morbidconditions, smoking and residency was noted for bothgroups (Table 1).Causes of injury and reasons for delay were explored andnoted for both ALI (Table 2) and CLI (Table 3) patents.S-4 A.R. Khan, F.A. Shaikh, A. Riaz, et al.Variable Acute Limb Ischemia Chronic Limb ischemiaGroup A  (n= 33) Group B (n= 22)GenderMale (%) 23 (69.69%) 12 (54.54%)Age in years (mean, SD) 8-90 (44.73±23.72) 34-90 (60.86±12.49)Co-morbidDM 1 (3%) 8 (36.36%)HTN 3 (9.09%) 0Combination 13 (39.39%) 9 (40.9%)None 16 (48.48%) 5 (22.72 %)Smoker 4 (12.12%) 8 (36.36%)Non-smoker 29 (87.87%) 14 (63.63%)Ex-smoker (Quit 10 years back) 0 0LocalityWithin the city 17 (51.51%) 10(45.54%)Outside the city 16 (48.48%) 12 (54.54%)DM: Diabetes Mellitus, HTN: HypertensionTable-1: Baseline Variables of Both Groups.Variable Sample Size (n=33)Mode of PresentationEmergency 31/33 (93.39%)OPD 02/33 (6.06%)CauseTrauma 18 (54.54%)    RTA 11 (61%)    Fall 05 (28%)    Penetrating trauma 02 (11%)Embolic 15 (45.45%)Time of Presentation    Mean 85.5 hrs (±92.67)    <12hrs 09/33 (27.27%)    >12hrs 24/33 (72.72%)Reasons for Delay    Non-referral by Physician 11/33(33.33%)    Patient unawareness 11/33(33.33%)    Access to a Vascular Surgeon 11/33(33.33%)    Financial Issues 0Limb Loss 20/33(60.60%)OPD: Out Patients Department, RTA: Road Traffic Accident.Table-2: Results of Acute Limb Ischemia (Group A).Why do patients with limb ischemia present late to a vascular surgeon?......Vol. 69, No. 01, (Suppl. 1) February 2019DiscussionThe cohort study looked into reasons for delayedpresentation of ALI and CLI patients to a vascular surgeon.The patients were classified into those from within oroutside the city of Karachi to avoid the bias of timerequired to travel to Karachi.Regarding patient population, our study is different fromearlier retrospective audits [10,12] as it included both caseof both types of ischaemia and looked into the reasonsfor delayed presentation.The difference in duration of delayed presentation ofpatients in both groups from within and outside the citywas statistically insignificant (p>0.05). This signifiesunawareness about the vascular diseases and about thepresence of vascular surgeons among both the patientsand the primary care physicians. The most likelyexplanation to this statement is that the patient belongingto Karachi, having quick access to a vascular surgeonround the clock, should ideally reach well in time, but theresults turned out to be different.Among various reasons, inability of primary care physicianto diagnose an ischaemic limb, both acute and chronic,and to timely refer the patient to a vascular surgeon stoodon top of the list. In a developing country like Pakistan, itis not uncommon to find the history of consultation witha general practitioner and following symptomatictreatment for initial period. The referral to a specialist isusually delayed till the condition gets worse, making itnearly impossible to achieve the ideal outcome. This ismainly due to unawareness about vascular diseases inthe general practitioners and partly due to lack of properreferral system in the national healthcare system.The other common reason is unawareness on the part ofpatients regarding vascular diseases as an entity. This isrelated to lack of proper awareness campaign and lowerliteracy rate countrywide. Working on both will help usachieve the desired outcomes.Non-availability of a vascular surgeon in the city was alsoa reason for delayed presentation in many ALI cases. Asper our knowledge, in the whole province of Sindh, onlyKarachi has three centres with qualified vascular surgeons,while the rest of the province is still waiting to have one.A formal fellowship in vascular surgery exists at AKUH,and it is approved by the College of Physicians andSurgeons Pakistan (CPSP). It produces at least one vascularsurgeon every two years. This is going to cater to theneeds of the province as well as the Country in the future.Only a minority of patients failed to consult a vascularsurgeon due to financial constraints, which was againstour expectations considering the level of poverty in thecountry and the lack of health insurance system.The rate of limb loss was significantly higher in bothgroups compared to earlier data13 for CLI and ALI.4,5 Astudy conducted in India14 mentioned amputation rateof 32% in patients who presented 24 hours after the onsetof ALI, which is nearly half that in our study, likely due tothe reasons mentioned above. Majority of these patientsare young or still working as seen in our study. The wholefamily is usually dependent on them. Loss of one limbaxes the income of the whole family. In terms of limitations,we did not include other centres of Karachi that alsoreceive ALI and CLI patients and that might affect theoverall picture. However, our hospital is serving a largeproportion of such patients. Also, we did not consider thelevel of arterial occlusion/injury in ALI cases, which is animportant risk factor along with timing as far as theS-5Variable Sample Size (n=33)Mode of PresentationEmergency 07/22 (31.8%)OPD 15/22 (68.18%)Presenting complaintRest pain and Discoloration 14/22(63.63%)Rest pain and non-healing ulcer 05/22 (22.7%)Discolouration (only) 03/22 (13.63%)Reasons for DelayNon-referral by Physician 13/22 (59%)Patient unawareness 08/22 (36.36%)Financial Issues 1/22 (4.54%)Access to a Vascular Surgeon 0Limb Loss 08/22 (36.36%)Table-3: Results of Chronic Limb Ischemia (Group B).Figure:  Mean Duration of Delay (Hours) Vs. Locality of patients with ALI.outcome of that limb is concerned. Another possiblelimitation is inclusion of patients coming from outsidethe city, but a separate analysis between patients fromwithin and outside the city ruled out that bias.The greatest strength of this study is being first of its kindto look into the reasons behind delayed presentation ofpatients with both types of  l imb ischaemia.Based on the findings, we recommend certain initiativesat various levels to improve the outcomes. Knowledgeabout vascular diseases in Pakistan is very limited. Wesuggest organising general awareness sessions regardingpresentation and immediate care of ALI and CLI cases indifferent cities. To reduce the delays, knowledge abouthospitals where qualified vascular surgeons are availableis to be spread across the country with the help ofelectronic and print media.It is important to improve awareness among the generalphysicians who receive majority of patients as being theprimary source of health provision. An awarenessprogramme regarding signs and symptoms of limbischaemia in different parts of the country with the helpof Pakistan Society for Vascular Surgery is going to go along way in that direction. To further strengthen it,workshops on emergency vascular surgery proceduresfor general surgeons have been organised in cities wherevascular surgeons are not available. Such workshops needto expand their area of coverage.Many medical graduates and surgical trainees are unawareof vascular surgery as a separate entity, since they neverget a chance to study or rotate in this specialty.  Inclusionof vascular surgery in the curriculum / training will greatlyenhance their understanding about this discipline. Thismight convince them to select vascular surgery as theirfinal career, hence more vascular surgeons will beproduced and available to serve the population at risk.Even if they turn out to be general practitioners, they willbe able to pick up the hard signs of ischaemia due tobackground knowledge acquired during training.Appropriate referral system from primary to secondaryand tertiary health care centres needs to be in place. Thiswill reduce the undue delays related to transfer of patients.Introduction of a national healthcare insuranceprogramme will support the general population in manyways.ConclusionThe common reasons for delayed presentation of bothALI and CLI patients to a vascular surgeon included non-referral by primary physician and unawareness in thegeneral population.Disclaimer: None.Conflict of Interest: None.Source of Funding: None.References1. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, FowkesFG, et al. Inter-society consensus for the management of peripheralarterial disease (TASC II). Eur J Vasc Endovasc Surg 2007;33(Suppl1):S1-S75.2. Creager MA, Kaufman JA, Conte MS. Acute limb ischemia. N EnglJ Med 2012;366:2198-206.3. Ouriel K, Shortell CK, DeWeese JA, Green RM, Francis CW, AzodoMV, et al. A comparison of thrombolytic therapy with operativerevascularization in the initial treatment of acute peripheral arterialischemia. J Vasc Surg 1994;19:1021-30.4. Eliason JL, Wainess RM, Proctor MC, Dimick JB, Cowan JA Jr,Upchurch GR Jr, et al. A national and single institutional experiencein the contemporary treatment of acute lower extremity ischemia.Ann Surg 2003;238:382-90.5. Earnshaw JJ, Whitman B, Foy C.  National Audit of Thrombolysis forAcute Leg Ischemia (NATALI): clinical factors associated with earlyoutcome. J Vasc Surg 2004;39:1018-25.6. Fowkes FG, Rudan D, Rudan I, Aboyans V, Denenberg JO, McDermottMM, et al. Comparison of global estimates of prevalence and riskfactors for peripheral artery disease in 2000 and 2010: a systematicreview and analysis. Lancet 2013;382:1329-40.7. Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC Jr, Goto S,et al. Statin therapy and long-term adverse limb outcomes inpatients with peripheral artery disease: insights from the REACHregistry. Eur Heart J 2014;35:2864-72.8. Kullo IJ, Rooke TW. Peripheral artery disease. N Engl J Med2016;374:861-71.9. Rutherford RB. Clinical staging of acute limb ischemia as the basisfor choice of revascularization method: when and how to intervene.Semin Vasc Surg 2009;22:5-9.10. Khan FH, Yousuf KM, Bagwani AR. Vascular injuries of the extremitiesare a major challenge in a third world country. J Trauma ManagOutcomes 2015;9:5.  doi:  10.1186/s13032-015-0027-0.11. Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S,et al. Recommended standards for reports dealing with lowerextremity ischemia: revised version. J Vasc Surg 1997;26:517-38.12. Kakar BK. Extremity vascular trauma experience at Civil SandamanTeaching Hospital & Bolan Medical College Quetta. Pak Heart J2012;37:42-48.13. Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, et al.Long-term prognosis of diabetic patients with critical limb ischemia:a population-based cohort study. Diabetes Care 2009;32:822-7.14. Turel M, Kumar PP, Stephen E, Agarwal S. A 10-year experience ofmanaging acute limb ischaemia in India. Natl Med J India2008;21:284-7.S-6J Pak Med AssocA.R. Khan, F.A. Shaikh, A. Riaz, et al.

Why do patients with limb ischaemia present late to a vascular surgeon? A prospective cohort study from the developing world

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Why do patients with limb ischaemia present late to a vascular surgeon? A prospective cohort study from the developing world

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