Presenting podium-first data on specialist chronic limb-threatening ischaemia (CLTI) clinics and rates of amputation, Assad Khan (Leeds, United Kingdom) provided an argument for “favourable” outcomes—including limb salvage—in a dedicated setting on the final day of the CX Symposium.
Briefly establishing the national incidence of CLTI in the United Kingdom, Khan noted the “rising number of cases placing increased strain on the finite capacity of vascular centres”. He said that, despite there being initiatives in place to improve limb salvage outcomes, the latest data “demonstrates significant and persistent disparities in the rate of major amputation across the country”, with a higher rate of CLTI-related amputation in the north of England. “This data confirms what we’ve always suspected and reiterates the need for a solution,” he told CX 2024.
Theirs was a prospective, observational cohort study, focused on comparing inpatient and outpatient 30-day amputation-free survival (AFS), mortality and amputation in CLTI patients between 28 March 2021 and 28 March 2023, excluding patients with diabetic foot infection, acute limb ischaemia, acute-on-chronic limb ischaemia and patients who were COVID-19 positive.
In total, 765 patients were included—415 inpatients and 350 outpatients. Khan reported that 251 and 269 patients in the inpatient and outpatient groups underwent revascularisation for limb salvage. Treatment was broadly similar, with just over 60% of patients in both cohorts undergoing endovascular intervention. Factors such as age, smoking status and median Rockwood Clinical Frailty Scale (CFS) were similar between groups, however, “inpatients were considerably more likely to have greater disease severity at presentation”, Khan detailed.
Their results showed 12-month AFS favouring the outpatient cohort—128 inpatients reaching this AFS timepoint compared with 194 in the outpatient group. “However, these data were not propensity matched,” Khan told delegates, “so are skewed by a large proportion of patients with Wound Ischemia and foot Infection (WIfI) stage four disease.” Subsequently, Khan and colleagues performed a subgroup analysis including patients with WIfI stage 2/3 disease who reported rest pain and tissue loss; “patients who are theoretically suitable for either inpatient or outpatient management,” Khan said. 172 outpatients achieved AFS at 12 months compared to 88 inpatients.
Survival regression analysis in this subgroup was propensity-matched for age, frailty and disease severity, and demonstrated that outpatients with WIfI Stage 2 and 3 disease are over 66% less likely to be amputated, and over 60% less likely to be amputated or die within 12 months, compared to inpatients with WIfI Stage 2 and 3 disease, but with no difference in 12-month mortality, “This difference in AFS is not driven by a survival advantage for outpatients” Khan noted. Additional benefits included a reduction in the likelihood of 30-day major adverse cardiovascular or limb events (MACE or MALE), the likelihood of complications as well as complication severity, and unplanned re-admission to hospital.
Reiterating the improved limb outcomes in outpatients who are treated at specialised CLTI clinics, Khan detailed cost disparities which favour outpatient treatment, estimating the average cost of a single inpatient to be £22,938 compared to £9,283 for an outpatient
Weighing each of these factors together, Khan concluded that specialised CLTI clinics are beneficial. Whilst financially more sustainable, the level of patient care that can be achieved in a dedicated environment wins out. “Our experience of providing specialist CLTI clinics is that they can treat all manner of patients, can achieve favourable limb-salvage rates, revascularise patients with fewer resources, provide alternative management strategies for CLTI, and improve patients’ quality of life.”
