Title: A Single Center's 15-Year Experience With Palliative Limb Care for Critical Limb Ischemia in Frail Patients
Abstract: Our institution’s multidisciplinary program “Prevention of Amputation in Veterans Everywhere” (PAVE) allocates veterans with critical limb-threatening ischemia (CLTI) to immediate revascularization, conservative treatment, primary amputation, or palliative limb care in accordance with previously reported criteria. These four groups align with the approaches outlined by the Global Guidelines for the management of CLTI. The goal of the present study was to delineate the natural history for the palliative group of patients and quantify the procedural risks and outcomes. Veterans prospectively enrolled in the palliative limb cohort of our PAVE program from January 2005 to January 2020 were analyzed. The primary outcome was mortality. The secondary outcomes included limb-related readmissions, limb loss, and wound healing. The Clinical Frailty Score and both 30-day and 5-year expected mortalities were calculated using the Veterans Affairs Quality Enhancement Research Initiative tool. The PAVE program enrolled 1158 limbs during the 15-year period. Of the 1158 limbs, 157 (13.5%) in 146 patients were allocated to palliative care—all had presented with tissue loss and various degrees of infection and severe ischemia. Also, 64% had WIfI (wound, ischemia and foot infection) stage 4, 18% stage 3, and 10% stage 1 or 2. The overall mortality of the group was 89.5% (median, 3 months after enrollment; range, 0-91 months). The predicted average 30-day mortality was 34%, and the expected 5-year mortality for the group was 66%. The average frailty score of the group was 6.3, denoting a person who is moderately to severely frail. Limb-related readmissions occurred an average of 0.3 time (range, 0-4). Eventual amputation was necessary in 18 limbs (11.5%) limbs. Wound healing occurred in 30 patients (19.6%), 6 of whom were still alive at the last follow-up. Despite their severe ischemia at presentation, this group carries a high procedural risk profile, low survival curves, and a low risk of limb-related complications leading to deferred primary amputation. In our cohort, the vast majority of patients had died within a few months of enrollment with their limb intact. The Veterans Affairs’ 5-year mortality tool underestimated the actual mortality. A comprehensive approach to the management of patients with CLTI should include a palliative limb care option because these patients have limited survival and could avoid unnecessary amputations.