Editor's Choice - Comparison of Prognosis in Chronic Limb Threatening Ischaemia after Revascularisation versus Non-revascularisation Treatment: Analysis of Japanese Regional Insurance Claims.

OBJECTIVE: While the prevailing practice for treating chronic limb threatening ischaemia (CLTI) is revascularisation, there is a limited understanding of disease progression in patients with CLTI who do not undergo this intervention. This study compared the prognosis of CLTI patients with tissue loss who underwent revascularisation with the prognosis of those who were managed with non-revascularisation treatment, investigating the efficacy of revascularisation in improving the outcome of patients with CLTI.

METHODS: Utilising the Shizuoka Kokuho Database, a regionally representative longitudinal cohort in Japan, this retrospective analysis examined CLTI patients with tissue loss (ulcer and gangrene), between April 2012 and September 2020, identifying two distinct cohorts: those receiving non-revascularisation treatment and those undergoing revascularisation. The primary endpoint was amputation free survival, evaluated in both cohorts after applying propensity score matching.

RESULTS: Of the 3 160 CLTI patients with tissue loss, 559 received non-revascularisation treatment and 589 underwent revascularisation. The non-revascularisation treatment predominantly involved prostaglandin E1 injections (99.1%). After one to one propensity score matching, the revascularisation cohort (372 patients) exhibited a markedly enhanced amputation free survival rate compared with their non-revascularisation counterparts (amputation free survival rate at one year: 58.0% vs. 45.7%, p = .014). Subgroup analyses underscored the greater efficacy of revascularisation across multiple categories, including males (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.47 - 0.75), patients with diabetes mellitus (HR 0.67, 95% CI 0.50 - 0.89), and patients with severe wounds (HR 0.76, 95% CI 0.61 - 0.93). However, the analysis did not find differences between the revascularisation and non-revascularisation treatment groups among female patients (HR 1.06, 95% CI 0.78 - 1.45) and patients with non-severe wounds (HR 0.87, 95% CI 0.58 - 1.30).

CONCLUSION: This regional Japanese cohort study revealed a potential enhancement in the amputation free survival rate post-revascularisation for CLTI patients with tissue loss compared with non-revascularisation treatment, except in female patients and patients with non-severe wounds. Additional studies are needed to further elucidate these results.