Two thirds of high-level amputations in those with PAD received low-intensity assessment. Here are the details on how to #ActAgainstAmputation

Using Medicare claims data from over 33,000 beneficiaries between 2016 and 2019, the investigators identified nearly 8,000 patients who underwent a major lower extremity amputation due to chronic limb-threatening ischemia (CLTI). Their findings offer a window into the continuum—or lack thereof—of care before amputation, and the inequities that pervade it.

Among their key findings:

• 63% of patients received low-intensity vascular care—meaning no diagnostic angiogram and no revascularization attempt—in the year before their major amputation.
• Low-income patients (defined by dual Medicare–Medicaid eligibility) had 35% lower odds of receiving high-intensity care.
• Men and individuals treated at safety-net hospitals were also significantly less likely to receive higher-intensity care.
• Patients who received low-intensity care were not only more likely to undergo above-knee amputations but also experienced higher mortality:
  • 40% died within two years post-amputation, compared to 34% among those who received higher-intensity care.

These are not merely practice pattern variations—they are potential missed opportunities. Importantly, even a diagnostic angiogram alone was associated with better survival, suggesting that proactive vascular evaluation may be protective, even when revascularization is not pursued.

The authors note:

“Despite community and societal efforts, increased resources, and advancements in vascular practice, ≈2 of every 3 patients with CLTI continue to not receive an angiogram or any attempt at revascularization before a nontraumatic CLTI-associated amputation.”

The study also reinforces a theme echoed across recent public health reports: where a patient lives, their income, and the type of hospital they access can all meaningfully influence outcomes—even in high-stakes situations like limb salvage.

Implications for Practice

This analysis strengthens the case for:

• Systematically tracking vascular assessments prior to major amputation.
• Integrating team-based, multispecialty care models that proactively engage patients before advanced tissue loss.
• Supporting under-resourced hospitals with clinical pathways and referral mechanisms to ensure equitable access to limb-preserving interventions.

In parallel with initiatives such as the American Heart Association’s goal to reduce nontraumatic amputations by 20% by 2030, this work offers both a benchmark and a challenge: How can we do better with what we already know? And how do we ensure that better is delivered equitably?

As we refine our approach to CLTI care, these data may help define a new quality metric: not just whether a limb is lost, but what diagnostic and therapeutic steps preceded that loss.

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📖 Citation:

Secemsky EA, Kirksey L, Quiroga E, et al. “Impact of intensity of vascular care preceding major amputation among patients with chronic limb-threatening ischemia.” Circ Cardiovasc Interv. 2024;17:e012798. https://doi.org/10.1161/CIRCINTERVENTIONS.122.012798