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A population-based study from 2013 to 2015 in Germany has found that nearly one fifth of patients with peripheral arterial disease (PAD) did not receive guideline-based vascular diagnostics three months before incidence amputation. Writing online in the European Journal of Vascular and Endovascular Surgery (EJVES), authors Kristina Hagenström (University Medical Center Hamburg-Eppendorf, Hamburg, Germany) and colleagues say this “reflects an underuse of health services”. In addition, the researchers report that, in one third of patients who did not receive vascular surgery, major amputation “probably could have been avoided”.

Due to a wider international variance in major amputation, high mortality rates and follow-up, and the “significantly reduced quality of life for patients with amputations,” the authors stress that vascular diagnostics and vascular surgery treatments “are of great importance” for lower limb preservation in patients with PAD. They note that patients with PAD have an increased risk of lower limb amputation, and that the prevalence of PAD and chronic limb-threatening ischaemia (CLTI) is expected to increase due to demographic trends.

The guidelines state that vascular diagnostic and vascular surgical treatments can contribute significantly to the preservation of the lower extremities, and also that early revascularisation can minimise the risk of amputation. In a retrospective longitudinal study, Hagenström et al examined these guideline-based procedures in patients before a first lower limb amputation and PAD.

The researchers analysed data from a large German statutory health insurance (SHI) scheme on patients with first amputation of lower extremities and PAD between 2013 and 2015. They considered pre-defined vascular diagnostic and vascular surgical procedures, as specified by guidelines with inpatients and outpatient care in a defined time before lower limb amputation, Hagenström and colleagues detail.

Reporting their findings in EJVES, the authors relay that the overall estimated incidence of lower extremity amputations in the total population was 0.12% from 2013–2015. Of these patients, they specify, 51.7% had PAD, 81.8% had received at least one diagnostic measure, and 61% a vascular surgery procedure before the lower extremity amputation.

Hagenström et al add that there were only minor variations in the use of diagnostic or surgical treatments between patients with major and minor amputations. “In total, 63.9% of patients had vascular surgery before the incidence major amputation compared with 60% of patients with a minor amputation,” they reveal.

The investigators highlight “noticeable” regional differences in the data, ranging from 91% (Berlin) to 67% (Bremen) regarding diagnostic procedures provided before amputation, and from 83% (Hamburg) to 55% (Saxony-Anhalt) regarding vascular surgery before amputations.

“Timely interventions by specialists and guideline-based treatments could reduce the number of amputations and subsequent costs,” the authors conclude. Commenting on the strengths of their study, they write that its design “permits analyses of a vast and unselected nationwide cohort” and is thus comparable with publications from other countries where population-based data were used. However, they stress that different healthcare systems must be considered.

Hagenström and colleagues also acknowledge some limitations of their study, including the fact that the analysed administrative data are based on only one of several SHI companies in Germany, which limits the transferability of the statements made to the population of Germany as a whole.

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