title: Peripheral arterial disease and critical limb ischaemia: still poor outcomes and lack of guideline adherence.
abstract: OBJECTIVE
  Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed.
  
  
  RESULTS
  From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €).
  
  
  CONCLUSIONS
  Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany DRG Research Group, University Hospital of Muenster, Muenster, Germany holger.reinecke@ukmuenster.de.
authors: Holger
authors: H
authors: Reinecke
authors: Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany Department of New Public Health, School of Human Sciences, Osnabrueck University, Osnabrueck, Germany.
authors: Michael
authors: M
authors: Unrath
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany.
authors: Eva
authors: E
authors: Freisinger
authors: DRG Research Group, University Hospital of Muenster, Muenster, Germany.
authors: Holger
authors: H
authors: Bunzemeier
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany.
authors: Matthias
authors: M
authors: Meyborg
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany.
authors: Florian
authors: F
authors: Lüders
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany.
authors: Katrin
authors: K
authors: Gebauer
authors: DRG Research Group, University Hospital of Muenster, Muenster, Germany.
authors: Norbert
authors: N
authors: Roeder
authors: Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany.
authors: Klaus
authors: K
authors: Berger
authors: Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany.
authors: Nasser M
authors: NM
authors: Malyar
mesh_terms: D000671:Amputation, Surgical / Q000706:statistics & numerical data; D057510:Endovascular Procedures / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000601:surgery*; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D017410:Practice Guidelines as Topic; D011859:Radiography; D015424:Reperfusion / Q000706:statistics & numerical data; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Amputation; Critical limb ischaemia; Endovascular; Mortality; Peripheral arterial disease