Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia

• Published in: Journal of vascular surgery Vol. 61; no. 1; pp. 162 - 169.e1
• Main Authors: Chung, Jayer, MD, Modrall, J. Gregory, MD, Ahn, Chul, PhD, Lavery, Lawrence A., DPM, Valentine, R. James, MD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.01.2015
• Subjects: Aged; Amputation - adverse effects; Amputation - mortality; Chi-Square Distribution; Chronic Disease; Combined Modality Therapy; Disease-Free Survival; Endovascular Procedures - adverse effects; Endovascular Procedures - mortality; Female; Humans; Ischemia - diagnosis; Ischemia - mortality; Ischemia - therapy; Kaplan-Meier Estimate; Limb Salvage; Lower Extremity - blood supply; Male; Middle Aged; Multivariate Analysis; Patient Care Team; Proportional Hazards Models; Retrospective Studies; Risk Factors; Severity of Illness Index; Surgery; Texas; Time Factors; Treatment Outcome; Vascular Surgical Procedures - adverse effects; Vascular Surgical Procedures - mortality; Wound Healing; Texas
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2014.05.101

Background This study was conducted to quantify the effect of multidisciplinary care (MDC) on amputation-free survival (AFS) and wound healing within a chronic critical limb ischemia (CLI) population. Methods We performed a retrospective, single-center cohort study of consecutive CLI patients presenting to the Vascular Surgery Service. Patients who received initial and follow-up wound care from the MDC were compared with patients who received standard wound care (SWC). The MDC team consisted of vascular, plastic, and podiatric surgeons who jointly managed wound care and directed any other consults or services as deemed necessary. SWC consisted of an inconsistent mix of providers without a defined manager, including nurses, wound care midlevel providers, general surgeons, internists, or the patients themselves. The referring physician determined the allocation of patients. The primary outcome variable was AFS, with a secondary evaluation of wound healing. The effects of baseline demographics, comorbid medical conditions, laboratory values, ischemic lesion severity and location, Rutherford classification, and participation in MDC were assessed. Significant univariate predictors ( P  < .10) of AFS were entered into a multivariate Cox regression model and assessed at an α = .05. Results Between August 2010 and June 2012, 146 CLI patients (91 male [63%]) were evaluated by the Vascular Surgery Service and were followed up for a median of 539 days (interquartile range 314-679 days). Ischemic tissue loss was present in 85 patients (38 at Rutherford category 5, and 47 at Rutherford category 6). Within this cohort, 51 (60%) had MDC, and 34 (40%) had SWC. Fifty-eight patients (68%) underwent revascularization (open in 17, endovascular in 35, and hybrid in 6), 14 (8%) were managed with primary major amputation, and 13 (15%) declined revascularization. AFS was superior for patients in the MDC arm vs the SWC arm (593.3 ± 53.5 days vs 281.0 ± 38.2 days; log-rank, P  = .02). Wound-healing times favored the MDC arm over the SWC arm (444.5 ± 33.2 days vs 625.2 ± 126.5 days), although this was not statistically significant (log-rank, P  = .74). Multivariate modelling revealed that independent predictors of major amputation or death, or both, were nonrevascularized patients (hazard ratio [HR], 3.76; 95% confidence interval [CI], 1.78-8.02; χ2 , P  < .01), treatment by SWC (HR, 2.664; 95% CI, 1.23-5.77; χ2 , P  = .012), and baseline nonambulatory status (HR, 1.89; 95% CI, 1.17-2.85; χ2 , P  < .01). Conclusions MDC pathways for the management of a population of CLI patients improved AFS by greater than twofold and should be the standard of care for the CLI population. Baseline nonambulatory status and unrevascularized patients also predict worse AFS. Wound healing remains prolonged regardless of preoperative or postoperative wound care. Future study is required to evaluate the costs and functional outcomes for MDC in the management of CLI.