Critical limb ischemia (CLI) represents the most aggressive form of peripheral vascular disease, with a lower survival rate than heart failure, stroke and most cancers.1 Yet inadequate attention is often given to a CLI diagnosis, with little regard for the associated danger of the disease process. With the current advancements in medical knowledge, how has there been such limited progress in the reduction of human loss caused by CLI? Just over 5 years ago, President Barack Obama signed into law the first legislation requiring comprehensive plans of research action for high-mortality cancers, with lung and pancreatic cancers given priority status for expedited attention. This landmark legislation, included in the National Defense Authorization Act of 2013, requires the National Cancer Institute (NCI) to develop scientific frameworks for addressing cancers with survival rates of less than 50%, with first-priority attention given to lung and pancreatic cancers. I commend the tireless work that raised awareness of the cancer threat to the level of the former President of the United States and applaud the noble action of the President to mandate increased focus upon diseases with dismal prognoses.
While the incidence of CLI continues to rise, the disease continues to result in the detrimental outcome of lower limb amputation with high mortality rates and astronomical healthcare costs. A recent study sponsored by the CLI Global Society showed that CLI attributes approximately $12 billion in annual costs. This study revealed that 29% of patients diagnosed with CLI will die or have a major amputation performed within the first year, and CLI patients commonly endure multiple revascularization procedures over a median survival of only 3.5 years. Four-year survival estimates were 38% with endovascular revascularization, 40% with surgical revascularization, and 23% with major amputation. Patients undergoing primary major amputation had the worst prognosis, regardless of clinical presentation severity.1
So why is the incidence of this deadly disease continuing to rise with limited focus or accountability in comparison to other diseases? For example, if you get admitted to the hospital with congestive heart failure, you will be assigned a diagnosis code and receive contemporary medical therapy with strict and standardized treatment guidelines. The same level of precision and consistency is noted with an influenza admission. There is a high amount of awareness and education among medical providers regarding these disease processes, the best and current treatment practices, and the importance of strict and consistent follow-up. Overall, the health care system provides superior care for these patients. Unfortunately, this same level of care, precision, and focus is not provided for our CLI patients. As there are no DRG or ICD10 codes for this advanced disease, there is no clear and consistent way to identify these patients or provide continuity of care upon a hospital admission. As a result, these very sick patients are often lost within our health care systems. They are frequently admitted under a variety of diagnosis codes which fail to accurately identify them as CLI patients. This allows their disease progression to go unnoticed until the pungent odor of their gangrenous toe brings the advancement of their disease to the forefront. Suddenly an urgent consult is made to a vascular specialist and a sad progression of events often occurs. The consultants see the patient and, while a physical exam is likely performed, over 50% of patients do not receive ANY type of vascular testing. Then the treating doctor comes to the rescue and makes the heroic decision to proceed with major amputation of the leg, explaining to the patient that this is the only option to solve their problem. Often the patient and their family feel gratitude that a physician finally provided care after days of the patient lying in bed with limited focus and attention upon their worsening disease. The heartbreaking part of this reality is the detrimental outcomes of amputation have been published countless times in well-respected, peer-reviewed journals with strong clinical data and evidence that supported completely opposite recommendations than the treatment the above patient received. In this day and age, how can it be possible that cutting off a patient’s leg is still a first-line treatment approach?
Every major vascular meeting around the globe specifically advises to NOT perform an amputation without a complete vascular evaluation, followed by some form of revascularization intervention. Compared to other revascularization procedures, amputation as first-line treatment is associated with shorter survival time, higher risk of subsequent amputation, and higher healthcare costs. Much effort is still needed to raise disease awareness, implement diagnosis codes to identify the disease, and establish evidence-based diagnostic algorithms and treatment pathways.1 My hope is to see an interdisciplinary network of medical providers work together to promote CLI awareness, education, and continuity of care, treating CLI with the same attention and urgency as one would treat a patient with heart failure or cancer. Don’t turn a blind eye to these terminally ill patients, because you could be the one that saves their life simply by ensuring a proper vascular work-up is performed. If you ever feel a CLI patient is not receiving the proper care or scheduled for an amputation of their lower leg without prior evaluation or intervention, DO YOUR PART AND ADVISE THE PATIENT TO GET A SECOND OPINION BEFORE THEY LOSE THEIR LEG AND LIFE. CLI is a silent, deadly epidemic without sufficient voice and representation. Raise awareness, speak up, and stop unnecessary major amputations.
Dr. Jihad Mustapha can be contacted at firstname.lastname@example.org.
1. Mustapha JA, Katzen BT, Neville RF, Lookstein RA, Zeller T, Miller LE, Jaff MR. Determinants of long-term outcomes and costs in the management of critical limb ischemia: a population-based cohort study. J Am Heart Assoc. 2018 Aug 21;21; 7(16):e009724. doi: 10.1161/JAHA.118.009724.