title: Current accepted hemodynamic criteria for critical limb ischemia do not accurately stratify patients at high risk for limb loss.
abstract: OBJECTIVE
  Critical limb ischemia (CLI) has been defined as rest pain or tissue loss in patients who have an ankle-brachial index (ABI) ≤0.50, ankle pressure (AP) <70 mm Hg, or toe pressure (TP) <50 mm Hg. Data suggesting that these patients are at high risk for limb loss without successful revascularization are limited. This study was designed to identify limb loss and mortality rates in patients who did not respond to revascularization or who were not revascularized to determine whether CLI hemodynamic criteria accurately identify patients at high risk for limb loss.
  
  
  METHODS
  Between 2008 and 2010, all patients undergoing lower extremity arterial duplex ultrasound testing at our hospital were identified. Those with ABI <0.50, AP <70 mm Hg, or TP <50 mm Hg were retrospectively reviewed to determine whether they had symptoms of rest pain, ischemic ulceration, or gangrene qualifying them for analysis in the database. Patients who underwent revascularization and subsequently had postrevascularization ABI, AP, or TP greater than the CLI criteria were removed from the cohort. Demographic factors, wound healing, amputation rates, and mortality were obtained and analyzed in relation to the initial APs and TPs. Outcomes were measured by Kaplan-Meier life-table analysis and Cox proportional hazards models.
  
  
  RESULTS
  In 381 patients identified in the study, 443 limbs met CLI criteria. After revascularization, 98 limbs with ABI or TP that improved to >0.5 and >50 mm Hg, respectively, were removed from the study cohort. In 45 limbs, patients did not respond to initial revascularization as their ABI, AP, or TP remained within CLI criteria. These limbs remained in the patient cohort, yielding a final group of 296 patients and 345 limbs. Mean follow-up was 2 years. In the entire patient cohort, limb loss occurred in 24% at 1 year and in 31% at 3 years. Mortality was 32% at 1 year and 56% at 3 years. Amputation-free survival was 54% at 1 year and 28% at 3 years. Lower TPs were associated with a statistically higher incidence of amputation. Among those with an initial TP ≤10 mm Hg (n = 85), limb loss occurred in 46% at 1 year and 60% at 3 years. This limb loss was significantly greater than limb loss among those with a TP of 31 to 50 mm Hg (n = 115; 18% at 3 years; P < .001) Amputation-free survival in patients with a TP ≤10 mm Hg was 8% at 3 years.
  
  
  CONCLUSIONS
  CLI is associated with a high mortality, but not all patients with currently defined hemodynamic criteria for CLI are at high risk of limb loss. Patients with a TP between 31 and 50 mm Hg (41% of the cohort) and not receiving revascularization or not responding hemodynamically to revascularization experienced a low risk of limb loss. We recommend revising the hemodynamic criteria for CLI to better identify patients at high risk for limb loss who require intervention to improve outcomes.
authors.affiliation: Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC. Electronic address: raghuveer_vallabhaneni@med.unc.edu.
authors.forename: Raghuveer
authors.initials: R
authors.lastname: Vallabhaneni
authors.affiliation: Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC.
authors.forename: Corey A
authors.initials: CA
authors.lastname: Kalbaugh
authors.affiliation: Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Ana
authors.initials: A
authors.lastname: Kouri
authors.affiliation: Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Farber
authors.affiliation: Division of Vascular Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.
authors.forename: William A
authors.initials: WA
authors.lastname: Marston
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects / Q000401:mortality; D055109:Ankle Brachial Index; D016009:Chi-Square Distribution; D016638:Critical Illness; D016208:Databases, Factual; D018450:Disease Progression; D018572:Disease-Free Survival; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex