ISSUE 54 EWJ web - Journal - Page 10
Missed Opportunities to Prevent
Major Lower Limb Amputation
by Mr Jonathan R Boyle
Consultant Vascular Surgeon,
The aging population and the increasing prevalence
of diabetes has led to a significant increase in patients
presenting to secondary care with the complications
of poor blood supply to the feet. The proliferating epidemic of peripheral arterial disease (PAD) has meant
that Vascular Surgery is predicted to be the specialty
of greatest increased demand in the US.
the lower the risk of amputation. This premise has
led to adoption of concepts such as “Time is Tissue”
and the “Need for Speed” when planning revascularisation (improving blood supply).
However, the evidence to support early treatment in
the scientific literature is not as robust as one might
expect. The increased focus on the management of
PAD and CLTI in clinical practice has been accompanied by an accompanying greater interest in scientific
research.
Symptoms of PAD range from intermittent
claudication, pain in the calves on walking, that is
quickly relieved by rest, to critical limb threatening ischaemia (CLTI) where patients develop pain in the
foot at rest, particularly at night, foot ulceration and
gangrene. These patients require urgent intervention
to improve the blood supply to save the foot and
prevent the need for major limb amputation.
The evidence that delays in treatment of CLTI lead
to not only a greater risk of major limb amputation,
but also death is now much better established in the
vascular literature. There is compelling evidence that
if a patient suffering from CLTI presents to a hospital
without a vascular service, then they on average
wait twice as long for revascularisation, leading to
significantly poorer outcomes.
Patients who are particularly at risk of PAD are current
or ex-smokers and those who suffer from diabetes,
high blood pressure and elevated blood cholesterol.
Those with symptoms should all be prescribed blood
thinning medication such as asprin or clopidogrel and
cholesterol lowering medication, statins, to slow disease progression and also to reduce the risks of heart
attack and stroke.
There are delays at all stages of the patient journey,
including initial presentation, accessing specialist community nurse and podiatric services, referral to secondary care, arterial imaging and revascularisation.
These patient pathways work more efficiently in locations where there are well established multidisciplinary teams of specialist nurses, podiatrists, vascular
technologists, diabetologists, vascular surgeons, interventional radiologists and specialist anaesthetists
working closely together to deliver timely care.
For those who present with CLTI there has been an
increasing focus on timely treatment to improve the
blood supply and prevent leg amputation in England
over the last few years. The Vascular Society of Great
Britain and Ireland produced a quality improvement
framework in 2019 and delivered an allied quality improvement programme from 2019-2023. The PADQIF demanded that vascular surgeons and
interventional radiologists met ambitious timelines to
improve blood supply by either surgical bypass or angioplasty (stretching arteries with balloons) with the
aim of preventing amputation. A 5-day target to improve blood supply was recommended for patients
who were admitted to hospital as an emergency with
CLTI and a 14-day target for those with slightly less
severe disease who were managed as outpatients.
Unfortunately, however there remain significant
geographical variations in access to care and in patient
outcomes. As vascular surgeons we spend a lot of time
trying to save patient’s legs, we don’t always succeed;
but there is little doubt that the earlier the blood supply to the foot is improved the better the chances of
limb salvage. Sadly however, despite best endeavour
many amputations are preventable.
References
Boyle JR, Atkins ER, Birmpili P, Pherwani AD, Brooks MJ,
Biram RWS, et al. A Best Practice Care Pathway for Peripheral Arterial Disease. J Vasc Soc GB Irel. 2022;1(Supp3):S1–
13. doi:10.54522/jvsgbi.2022.017https://www.vsqip.org.uk/
content/uploads/2022/05/PAD-QIF-2022-Update.pdf
In 2022 NHS England recognising the importance of
the 5-day target chose to support the PAD-QIP by
adopting this target as one of the specialised commissioned CQUINs (Commissioning for Quality and Innovation).
Birmpili P, Behrendt CA, Boyle JR. Revascularisation for
Chronic Limb Threatening Ischaemia - The Need for
Speed. Eur J Vasc Endovasc Surg. 2023;66(2):158-159.
The CQUIN has further focused vascular surgeons
on improving the blood supply to the affected foot or
feet as soon as possible. To a certain extent it seems
common sense that if the foot is dying because of lack
of a sufficient blood supply then the sooner this can be
restored the better the chance of the foot healing and
EXPERT WITNESS JOURNAL
Li Q, Birmpili P, Johal AS, Waton S, Pherwani AD, Boyle
JR, et al. Delays to revascularization for patients with chronic
limb-threatening ischaemia. Br J Surg. 2022;109:717–26.
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APRIL 2024