What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons

Abstract

Introduction The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK. Methods A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign. Results Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF’s 5-day ‘admitted care’ pathway is achievable, only 28.6% thought the 14-day ‘non-admitted care’ pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment. Conclusions The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an ‘urgent’ model of care may help to potentially overcome these challenges.

The Impact of the COVID-19 Pandemic on a Dedicated Vascular Emergency Clinic

“…The outpatient management for patients with CLTI is notoriously challenging, however, with a recent UK survey demonstrating that only 14.3% of centres provide an outpatient consultation within the seven-day referral target. 24 The success of our outpatient clinics relied on the streamlining of patient care, with individuals undergoing a “one stop” clinic that provided assessment and investigations. Additionally, all patients awaiting intervention were routinely swabbed for COVID-19 and methicillin-resistant Staphylococus aureus to facilitate the use of day case angiogram slots and admission for open surgery procedures.…”

The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise

“…CLTI is associated with an increased risk of major limb amputation and mortality2–4 and urgent treatment is required for an optimal prognosis. However, studies examining the care pathway from first symptom to intervention have described how delays can occur at each stage of the process,5 starting with the identification and referral of patients with CLTI6 and also at the time of assessment by vascular services 7. To avoid these, organisations have introduced various initiatives, such as regular ‘hot clinics’ (which are for emergency referrals only) and streaming patients to specific services such as podiatry.…”

“…However, studies examining the care pathway from first symptom to intervention have described how delays can occur at each stage of the process, 5 starting with the identification and referral of patients with CLTI 6 and also at the time of assessment by vascular services. 7 To avoid these, organisations have introduced various initiatives, such as regular ‘hot clinics’ (which are for emergency referrals only) and streaming patients to specific services such as podiatry. However, this increases the complexity of the care pathway and there is limited evidence for services to draw on when considering how to organise vascular services so that they meet the needs of the local population and ensure patients with CLTI have rapid access to endovascular or open surgery.…”

Hospitalization and Death in the First 30 days After Outpatient Lower Extremity Arterial Stenting

“…Consequently, outpatient endovascular revascularization has become the main option for arterial repair in the United States of America (USA) where the Outpatient Prospective Payment System significantly promotes the shift from inpatient to outpatient settings [13]. However, outpatient setting for LEAD remains low elsewhere [14], notably in France where the proportion of outpatients average 5% and stable since 2016. Some studies showed that procedural and postoperative complications of endovascular revascularization within 30 days of surgery occur in 10% to 13% of the patients [15,16].…”