July 2021 | Issue 90
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Peter Schneider New tools for CLTI
FORS: First use of new technology in the USA page 14
Vascular community rallies to reduce “devastating” lowerextremity amputations
“To stop, and indeed reverse, the increasing trend of amputation, actionable policies that will reduce the incidence of chronic limb-threatening ischaemia [CLTI] and enhance delivery of optimal care are needed”, a recent policy statement by the American Heart Association (AHA) begins. The Association has set a target to reduce non-traumatic lower-extremity amputations by 20% by 2030.
M
ark A Creager, director of the Heart and a “great unmet need worldwide” for quicker diagnosis Vascular Center at Dartmouth Hitchcock and treatment, he remarked. Medical Center (Lebanon, USA) and Writing in the April edition of Circulation, Creager colleagues, on behalf of the AHA Advocacy and colleagues propose a series of actions, focused on Coordinating Committee, describe non-traumatic lowerexpanding availability and accessibility, improving extremity amputation as a “devastating complication” public awareness of PAD, and the greater use of of peripheral arterial disease (PAD), noting a significant effective PAD management strategies. They also suggest impact on patients and society. ways in which regulatory and institutional policies can They recognise that, while amputation is an help to facilitate the AHA’s recommended changes. “important and potentially sole treatment option” for certain patients, it “often is preventable”, Healthcare disparities necessitate even among patients with advanced PAD. focus on “availability and The AHA believes there is “considerable accessibility” of care opportunity” to improve the care of patients with The authors cite poverty, racial disparities, and PAD and thereby reduce the risk of CLTI, foot geographic limitations as factors that can increase ulceration, and limb amputation. a person’s risk of amputation and therefore must be Creager and colleagues write that a number of considered in any policy recommendations. The AHA evidence-based diagnostic and therapeutic Creager and colleagues note a “complex” has set a target to reduce approaches can reduce amputation risk. association between poverty and prognosis non-traumatic lowerHowever, their implementation and adherence with PAD. They write that, among patients extremity amputations by are “suboptimal” for a variety of reasons. with severe PAD, such as CLTI, those with BY 2030 dual eligibility for Medicare and Medicaid had These include the underdiagnosis of PAD, lack of knowledge among patients and healthcare higher mortality and amputation risk compared professionals regarding PAD management, with those eligible only for Medicare, which is inadequate access to vascular or foot care specialists, “likely to reflect that people with dual eligibility have a and medical cost. high risk factor profile”. “Racial disparities in the USA are dramatic”, the authors Data highlight “concerning” trends in add. They note that, among Medicare beneficiaries with amputation levels diabetes and PAD, four-fold differences in amputation risk While several reports have shown a general decrease in are recognised between Black Americans and other racial amputations, Creager et al detail, recent data from the or ethnic groups. National Inpatient Sample paint a different picture. The Regarding geographical disparities, Creager and authors highlight “concerning” trends noted by Linda S colleagues relay that the Mountain region in the USA Geiss (Centers for Disease Control and Prevention, Atlanta, observed 5,550 amputations per 100,000 patients with USA) et al in a 2019 Diabetes Care report regarding PAD, compared to 8,400 in the East South Central region. patients with diabetes. Creager and colleagues identify a “Improving access to care through insurance expansions “recent resurgence” of amputation rates among this patient and increasing the availability and accessibility to group in Geiss and colleagues’ data: after a 43% decline interventions that reduce the risk of amputation would be between 2000 and 2009, the amputation rate increased by necessary components to affect amputation rates among 50% from 2009 to 2015. high-risk populations”, the authors propose. While the data mentioned in the AHA statement focus largely on the USA, recent dialogue at the Charing Increasing awareness of PAD is “critical” Cross (CX) 2021 Digital Edition (19–22 April, online) Another of the actions the AHA recommend is improving highlighted the global nature of the problem. In a public awareness of PAD. The authors stress that this is a roundtable discussion with the CLI Global Society, Barry “critical” element, as a current lack of awareness among Katzen (Miami Cardiac and Vascular Institute, Miami, clinicians and patients is hindering the diagnosis and USA) noted that, “in many parts of the world, the most management of the condition. common vascular procedure is an amputation”. There is Continued on page 4
20%
Profile: Ali AbuRahma page 20
Large study shows continued and quickening decline in AAA mortality According to a new, populationbased analysis, abdominal aortic aneurysm (AAA) mortality has continued to decline, and “at a faster rate than ever” in the second decade of the 21st century. Authors C Y Maximilian Png (Massachusetts General Hospital, Boston, USA), Edward Choke (Sengkang General Hospital, Singapore), and colleagues attribute this continued and accelerating decline to multiple factors, highlighting in particular the impact of sustained reductions in smoking and hypertension. THE AUTHORS DESCRIBE THEIR work, published as an Editor’s Choice Paper in the June edition of the European Journal of Vascular and Endovascular Surgery (EJVES), as the largest population-based analysis of AAA mortality to date, incorporating data from 17 countries across four continents. Despite the evidence showing a strong general trend, Png, Choke, et al do acknowledge and detail heterogeneity among countries included in the study and notable geographical limitations. It is known that the early 21st century witnessed a decrease in mortality from AAA, the authors begin, noting an association with “variations in the prevalence of cardiovascular risk factors”. The aim of this study was to investigate whether this trend had continued into the second decade of the century by looking at data from 2001 through 2015. The researchers first extracted the International Classification of Disease codes for AAAs, thoracoabdominal aortic aneurysms, and aortic aneurysms of unspecified site (both ruptured and without rupture) from the World Health Organisation (WHO) mortality database. In addition, they collected data on risk factors from the Institute of Health Metrics and Evaluation and WHO InfoBase, as well as data on population from the World Development Indicators database. In order to be included in the analysis, countries had to have <30% of mortality data missing and at least 10 annual AAA-related deaths, the authors communicate. Out of the 17 countries included in total, 11 were European, and two each were Australasian, Continued on page 6