Limb Salvage: The Heart and Soul (Sole?) of Vascular Surgery

Compelling stuff from Behrendt and Debus in European Journal of Vascular and Endovascular Surgery

It can sometimes be challenging to understand the self concept of vascular surgery in a time where the aorta dominates both conferences and journals. While pioneers in interventional vascular surgery use highly innovative techniques to climb mount vascular, the vast majority set up camp at the foot of this mountain. Globally, more than 200 million patients suffer from peripheral arterial occlusive disease, 1 and some 500 million patients suffer from diabetes. 2 Besides major cardiovascular outcomes, including death, limb salvage is an urgent priority for this vulnerable group of patients. A previous VASCUNET report on non-traumatic amputations of the lower limb highlighted remarkable variations between 12 European and Australasian countries, which led to a heated discussion about underlying reasons and validity of studies in this research field. 3 In fact, we sometimes compare apples and oranges in cross border research. There are numerous weaknesses in the available studies, including for instance, the varying discrimination between major and minor amputations, lacking linkage of patient related data leading to distorted results, or insufficient external validity of study data. In addition, the number of vascular specialists per 100 000 inhabitants may vary considerably between countries. Hughes et al. have added important knowledge by comparing trends in lower limb amputation incidence in 15+ European Union countries from 1990 to 2017. 4 The authors used data obtained from the Global Burden of Disease (GBD) Study 2017 to determine incidence trends over a remarkably long period of nearly 30 years. Yet again, the authors had to use an individual definition to describe the amputation level as “proximal to toes” vs. toe amputation, making it challenging to compare study results with previous reports. For amputations proximal to toes, they observed increasing trends in six of 19 countries and decreasing trends in nine countries. The age standardised incidence rates varied widely between below 20 per 100 000 in the Netherlands to more than 30 per 100 000 in Australia. As for Australia, the previous VASCUNET amputation report observed considerably lower major amputation rates, certainly using a different definition (above the ankle level) and another database. Unfortunately, no data from Hungary were available in the current study to make a direct comparison, as Hungary was previously identified as an outlier with a markedly high incidence of major amputation. Beyond possible study limitations and the inability of observational studies to prove causal relationships, it can be expected that the interesting and important study by Hughes et al. will lead to further research and quality improvement programmes. 4 The authors should be congratulated for bringing this big dataset together and for significantly improving the knowledge base on an important quality indicator comprising several millions of patients worldwide. It is important to continue the ongoing methodological controversy and discuss how real world evidence can further improve through harmonisation.To read this article in fu

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