title: Not All Patients with Critical Limb Ischaemia Require Revascularisation.
abstract: OBJECTIVE
  International guidelines recommend revascularisation as the preferred treatment for patients with critical limb ischaemia (CLI). Most contemporary research focuses on the outcome of invasive procedures for CLI, but little is known about the outcome of conservative management. Amputation free survival (AFS) and overall survival (OS) was investigated in patients with CLI who did or did not receive revascularisation, and characteristics associated with clinical outcomes were explored.
  
  
  METHODS
  This was a retrospective cohort study of consecutive patients with chronic CLI between 2010 and 2014 in a Dutch university hospital. CLI was defined as the presence of ischaemic rest pain or tissue loss in conjunction with an absolute systolic ankle pressure < 50 mmHg or a toe pressure < 30 mmHg. Patients were divided into invasive (revascularisation within 6 weeks), deferred invasive (revascularisation after 6 weeks), or permanently conservative treatment groups. Univariable and multivariable survival analyses were used to identify factors associated with AFS and OS.
  
  
  RESULTS
  The majority (66.7%; N = 96) of the identified 144 patients with CLI (mean age 71.2 years; median follow-up 99 weeks) underwent revascularisation within 6 weeks of diagnosis. Deferred invasive treatment was provided in 18.1% (N = 26) patients and 22 patients (15.3%) were treated permanently conservatively. AFS and OS did not differ significantly between the three groups (Breslow-Wilcoxon p = .16 for AFS and p = .09 for OS). Age, chronic obstructive pulmonary disease (COPD), and heart disease were significant independent predictors of AFS. Age, COPD, and hypertension were significant independent predictors of OS. Treatment was not a significant predictor of either AFS or OS.
  
  
  CONCLUSIONS
  Not all patients with CLI require revascularisation to achieve an AFS that is similar to patients undergoing revascularisation, although the efficacy of conservative versus invasive treatment in CLI patients is still unclear. Further prospective studies should determine subgroups of patients in whom revascularisation may be omitted.
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands. Electronic address: t.b.santema@amc.uva.nl.
authors.forename: T B
authors.initials: TB
authors.lastname: Santema
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: R M
authors.initials: RM
authors.lastname: Stoekenbroek
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: J
authors.initials: J
authors.lastname: van Loon
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: M J W
authors.initials: MJ
authors.lastname: Koelemay
authors.affiliation: Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands.
authors.forename: D T
authors.initials: DT
authors.lastname: Ubbink
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D018572:Disease-Free Survival; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009426:Netherlands; D018579:Patient Selection; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D019564:Unnecessary Procedures
keywords: Amputation free survival; Conservative management; Critical limb ischaemia; Major amputation; Peripheral vascular disease; Revascularisation