Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital of Muenster, Muenster, Germany DRG Research Group, University Hospital of Muenster, Muenster, Germany
Institute of Epidemiology and Social Medicine, University of Muenster, Muenster, Germany Department of New Public Health, School of Human Sciences, Osnabrueck University, Osnabrueck, Germany.
Eur Heart J. 2015 Apr 14;36(15):932-8. doi: 10.1093/eurheartj/ehv006. Epub 2015 Feb 2.
Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed.
From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €).
Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.
仅有少数历史研究报告外周动脉疾病（PAD）和严重肢体缺血（CLI）的预后不良。应评估当代的治疗和结局状况。
从德国最大的公共医疗保险中，回顾性地获得了 2009-2011 年期间因 PAD 住院的 41882 例患者的所有门诊和住院诊断及手术数据，随访至 2013 年。患者被分为 Rutherford 分类 1-3（n=21197）、4（n=5353）、5（n=6916）和 6（n=8416）。具有高血压、血脂异常和吸烟等经典危险因素的患者比例随着 Rutherford 分类的增加而降低（均 P<0.001），而糖尿病、慢性肾脏病和慢性心力衰竭则增加（均 P<0.001）。在晚期 PAD 中，血管造影和血运重建术的应用频率较低（均 P<0.001）。住院截肢率从 Rutherford 1-3 的 0.5%连续增加到 Rutherford 6 的 42%，心肌梗死、中风和死亡的发生率也增加（均 P<0.001）。在 4298 例接受 CLI 截肢的患者中，有 37%的患者在指数住院期间或之前的 24 个月内未接受任何血管造影或血运重建术。在随访期间（平均 1144 天），有 7825 例患者截肢，10880 例患者死亡。Kaplan-Meier 模型预测 Rutherford 1-3、4、5 和 6 类患者的 4 年死亡率分别为 18.9%、37.7%、52.2%和 63.5%，截肢的 4 年死亡率分别为 4.6%、12.1%、35.3%和 67.3%。多变量 Cox 回归模型显示，PAD 分类是死亡、截肢、心肌梗死和中风的显著预测因素（均 P<0.001）。住院时间（5.8±6.7 天、10.7±11.1 天、15.2±13.8 天和 22.1±20.3 天；P<0.001）和平均病例费用（3662±3186 欧元、5316±6139 欧元、6021±4892 欧元和 8461±8515 欧元；P<0.001）随着 Rutherford 1-3、4、5 和 6 的增加而持续增加。尽管只有 49%的患者患有 CLI，但这些患者产生了 65%的住院费用（1.41 亿欧元），在随访期间产生了 56%的费用（3.36 亿欧元）。
尽管 PAD 治疗近期取得了进展，但目前的结局仍然较差，尤其是在 CLI 患者中。尽管血管重建术可显著降低肢体丧失率，但 CLI 患者接受的血管造影和血运重建术仍然明显减少。
