Alik Farber, MD

38 Pages·2017·2.54 MB·English

by  Partners Information Systems

Update on BEST-CLI Trial
Alik Farber, M.D.
Professor and Chief
Division of Vascular and Endovascular Surgery
Boston Medical Center
Boston University School of Medicine
Disclosures
Trial Co-Chair
 Supported by NHLBI: 1U01HL107407-01A1

A Growing Problem

PAD/CLI
Elderly
Metabolic
Syndrome
Obesity
Diabetes
An Expensive Problem

• Medicare expenditure on CLI > $4 billion

(CHF = $3.9B, Cerebrovascular disease = $3.7B)

– 90% inpatient care

– $1,700 per patient
(>2X avg beneficiary)

– 3% of total Medicare budget
(THR = 0.9%, TKR 1.7%)
Natural History of Critical Limb Ischemia
>1,500 patients in 13 studies at 1 year f/u
--22% mortality
--35% worsening tissue loss
--22% major amputation rate
Goals Of Treatment
• Medical therapy to optimize cardiovascular risk
• Measures to improve limb perfusion
(revascularization)
– Relieve pain
– Heal wounds
– Preserve a functional limb
– Maintain ambulatory status
Hirsch AT et al. J Am Coll Cardiol 2006;47:1239-131
Conte MS and Farber A. BJS 2015;102:1007-1009
Current State of Affairs in CLI
 Most CLI is treated with infrainguinal revascularization

Endovascular
Therapy
Bypass
Surgery
Current State of Affairs in CLI
 Most CLI is treated with infrainguinal revascularization
 There is great variation in amputation and revascularization
rates in patients with CLI
(Dartmouth Atlas, 1998)
 Amputation rates among certain groups are rising
(Humphries JVS
2016)
 There is variability in intensity of vascular care across regions
of the United States
(Goodney. Circulation CV 2012)
 There is great variability in how open surgery and
endovascular therapy is utilized to treat CLI
(Menard. JAHA 2016)
Critical Limb Ischemia: % Treated by Bypass (vs. PVI)

100% Bypass
100%
90%
80%
70% Procedure Selection Variation
60%
50%
40%
30%
20%
10%
0%
VQI Centers
0% Bypass