title: Analysis of the Elective Treatment Process for Critical Limb Ischaemia with Tissue Loss: Diabetic Patients Require Rapid Revascularisation.
abstract: OBJECTIVE
  The number of elderly people is increasing; inevitably, the result will be more patients with critical limb ischaemia (CLI) in the future. Tissue loss in CLI is related to a high risk of major amputation. The aim of this study was to analyze the treatment process from referral to revascularisation, to discover possible delays and reasons behind them, and to distinguish patients benefitting the most from early revascularisation.
  
  
  METHODS
  A retrospective analysis was performed of 394 consecutive patients with a combined 447 affected limbs, referred to the outpatient clinic during 2010-2011 for tissue loss of suspected ischaemic origin.
  
  
  RESULTS
  For 246 limbs revascularisation was scheduled. After changes in the initial treatment strategy, endovascular treatment (ET) was performed on 221 and open surgery (OS) on 45 limbs. Notably there was crossover after ET in 17.0% of the procedures, and re-revascularisations were required in 40.1% after ET and 31.1% after OS. The median time from referral to revascularisation was 43 days (range 1-657 days) with no significant difference between ET and OS. For 29 (11.8%) patients the ischaemic limb required an emergency operation scheduled at the first visit to the outpatient clinic. For 25 (10.2%) patients the situation worsened while waiting for elective revascularisation and an emergency procedure was performed. Diabetic patients formed the majority of the study population, with 159 diabetic feet undergoing revascularisation. In multivariate analysis, diabetes was associated with poor limb salvage. When revascularisation was achieved within 2 weeks, no difference was seen in limb salvage. However, when the delay from first visit to revascularisation exceeded 2 weeks, limb salvage was significantly poorer in diabetic patients.
  
  
  CONCLUSIONS
  Diabetic ulcers always require vascular evaluation, and when ischaemia is suspected the diagnostics should be organised rapidly to ensure revascularisation without delay, according to this study within 2 weeks from the first evaluation.
authors.affiliation: Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland. Electronic address: katariina.noronen@hus.fi.
authors.forename: K
authors.initials: K
authors.lastname: Noronen
authors.affiliation: Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland.
authors.forename: E
authors.initials: E
authors.lastname: Saarinen
authors.affiliation: Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland.
authors.forename: A
authors.initials: A
authors.lastname: Albäck
authors.affiliation: Faculty of Medicine, University of Helsinki, Helsinki, Finland; Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland.
authors.forename: M
authors.initials: M
authors.lastname: Venermo
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D016638:Critical Illness; D017719:Diabetic Foot / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D017558:Elective Surgical Procedures; D004630:Emergencies; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D016016:Proportional Hazards Models; D012017:Referral and Consultation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects; D014945:Wound Healing
keywords: Diabetic foot; Ischaemic ulcer