Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ, et al.
Journal of vascular surgery. Date of publication 2015 Jan 1;volume 61(1):162-9.
1. J Vasc Surg. 2015 Jan;61(1):162-9. doi: 10.1016/j.jvs.2014.05.101. Epub 2014 Jul
26.
Multidisciplinary care improves amputation-free survival in patients with chronic
critical limb ischemia.
Chung J(1), Modrall JG(2), Ahn C(2), Lavery LA(2), Valentine RJ(2).
Author information:
(1)Division of Vascular and Endovascular Surgery, The University of Texas
Southwestern Medical Center, Dallas, Tex. Electronic address:
jayer.chung@utsouthwestern.edu.
(2)Division of Vascular and Endovascular Surgery, The University of Texas
Southwestern Medical Center, Dallas, Tex.
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; χ(2), P < .01), treatment by SWC (HR, 2.664; 95% CI,
1.23-5.77; χ(2), P = .012), and baseline nonambulatory status (HR, 1.89; 95% CI,
1.17-2.85; χ(2), 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.
Copyright © 2015 Society for Vascular Surgery. Published by Elsevier Inc. All
rights reserved.
DOI: 10.1016/j.jvs.2014.05.101
PMID: 25073577 [Indexed for MEDLINE]
