Six of the Best, Vascular 21

Aims: To determine management of patients with critical lower limb ischaemia (CLI) from first presentation to investigation and treatment. Methods: One-year prospective survey (May 2000–May 2001). Follow-up: 3–15 months. Results: Some 873 arterial cases presented, 134 patients had CLI. Of the latter, 49 per cent were men, 30 per cent diabetic, the median age was 81 years. Only 15 (24 per cent) of the 62 cases were referred to outpatients as urgent. Vascular consultants reviewed all GP referral letters and the patients were prioritized. Significantly more patients were prioritized as soon or urgent by vascular consultant surgeons that by GPs (P < 0.001). Patients waited a median of 25 days to be seen in outpatients, and had symptoms for a median of 8 weeks. Treatment was conservative for 70 patients, and 11 primary amputations, 6 secondary amputations, and 62 revascularization procedures (34 operative, 28 percutaneous transluminal angioplasty) were performed. At follow-up (3–15 months, median 9 months), rates of major amputation and death were 12 and 27 per cent, respectively. Significantly more diabetics underwent major amputation (P < 0.02) than nondiabetics. Patients presenting with ulceration or gangrene were at greater risk of death than those with rest pain alone (P < 0.01). Conclusion: Patients with CLI often have symptoms for many weeks before being seen by a specialist, and 76 per cent are referred as nonurgent cases. This compares with patients with suspected malignant disease who are required to be seen within 2 weeks.