CLI Global Society Statement Regarding New York Times Article
This document is written in response to a recent article published in the New York Times on July 15, 2023, regarding healthcare and limb loss. The Critical Limb Ischemia (CLI) Global Society is a nonprofit, multidisciplinary membership-based organization of healthcare providers committed to amputation prevention, thereby improving the lives of patients suffering from critical limb ischemia, the most severe form of peripheral arterial disease (PAD). CLI is a devastating manifestation of atherosclerosis that affects the lower extremities. The Society’s mission is to “improve quality of life by preventing amputations and death due to critical limb ischemia” worldwide through patient advocacy, education, and awareness of the problem. The mission is reinforced on the Society website, in published annual reports, and in all associated scientific presentations.
CLI is a severely underdiagnosed and undertreated disease with a significant risk of amputation and mortality. It is estimated between 1 and 3 million Americans suffer from CLI1. Left untreated, CLI can lead to non-healing wounds, gangrene, amputations, and eventually death. 60% of patients who undergo amputation due to PAD or CLI die within two years, surpassing the five-year mortality rate for patients with breast, colon, and prostate cancer2.
The Society was formed in January 2016 to address the unmet clinical needs of patients with CLI and advocate for increased awareness and emphasis on this disease state. We are not focused on the entity of claudication, which is a manifestation of a less advanced form of PAD. The multidisciplinary leadership and membership include Vascular Surgeons, Interventional Cardiologists, Interventional Radiologists, Vascular Medicine Specialists, Podiatrists, Wound Care Specialists, Allied Health Professionals, and other healthcare providers committed to improving the outcomes of CLI, including disparities in care based on race, economics, and gender, to enhance limb preservation and reduce mortality in all patients with this disease.
The Society collaborates with like-minded organizations that share an interest in improving the lives of patients with CLI. We strongly desire to aggregate various backgrounds, perspectives, and experiences to address patient access to care, diagnosis, treatment, and outcomes to improve patient care and prevent amputations globally.
Important statistics about CLI:
- Patients from racial and ethnic minority groups experience higher incidence and worse outcomes of PAD, with 2 to 5 times higher amputation rates than white patients.3
- An estimated 300 non-traumatic amputations occur every day in the United States.4
- 85% of amputations due to CLI could be avoided.5
- 51% of patients undergoing primary major amputation for CLI receive no previous attempts at revascularization to preserve the limb.2
- Up to 61% of patients die within 2 years of undergoing an amputation for CLI.2
- Up to 78% of patients die within 4 years of undergoing an amputation CLI.2
- Only one-third of patients with CLI are prescribed optimal medical therapy.6
- Successful revascularization with bypass surgery or minimally invasive techniques doubles patient survival compared to amputation.7
- Major and minor amputation rates have increased by 50% from 2009 to 2015, with increasing rates more pronounced in younger adults with diabetes and PAD, who are at the highest risk for lower-extremity amputations.8
- The recent BASIL-2 and BEST-CLI trials have highlighted the significant cardiovascular mortality associated with this disease, regardless of the treatment strategy (endovascular vs surgery). 9-10
The Journal of Critical Limb Ischemia is a unique publication associated with the Society and the only scientific journal focused solely on CLI and amputation prevention. The Journal publishes peer-reviewed articles focused on clinical care, research, and education. Each manuscript undergoes multiple independent peer reviews and is then vigorously reviewed by an editorial board and managing editor. A significant milestone was reached as the Journal was recently accepted by SCOPUS, the largest abstract and citation database of peer-reviewed literature, with anticipated submission to PubMed before the end of this year.
It is the fervent hope of the CLI Global Society that the recently published article in the New York Times does not serve to inhibit or discourage patients from seeking appropriate care needed to prevent amputation and improve their morbidity, mortality, and quality of life.
- Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017;69:e71–e126.
- Jihad A. Mustapha MD, Barry T. Katzen MD, Richard F. Neville MD, Robert A. Lookstein MD, Thomas Zeller MD, Larry E. Miller PhD, Michael R. Jaff DO. Determinants of Long-Term Outcomes and Costs in the Management of Critical Limb Ischemia: A Population-Based Cohort Study. J Am Heart Assoc. 2018;7:e009724. DOI: 10.1161/JAHA.118.009724.
- Newhall K, Spangler E, Dzebisashvili N, Goodman DC, Goodney P. Amputation rates for patients with diabetes and peripheral arterial disease: the effects of race and region. Ann Vasc Surg. 2016; 30:292-298.e1. doi: 10.1016/j.avsg.2015.07.040
- Creager MA, Matsushita K, Arya S., Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel, LP Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association Circulation. 2021;143:e875-e891
- Singh G, Chawla S. Amputation in Diabetic Patients. Med J Armed Forces India. 2006 Jan;62(1):36-9. doi: 10.1016/S0377-1237(06)80151-6. Epub 2011 Jul 21. PMID: 27407841; PMCID: PMC4923303.
- Chung J, Timaran DA, Modrall JG, et al. Optimal medical therapy predicts amputation-free survival in chronic critical limb ischemia. J Vasc Surg. 2013;58:972-980.
- Mustapha JA, Katzen BT, Neville RF, et al. Disease burden and clinical outcomes following initial diagnosis of critical limb ischemia in the Medicare population. JACC Cardiovasc Interv. 2018;11:1011-1012.
- Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res 1015;116;1509-1526. doi: 10.1161/CIRCRESAHA.116.303849.
- Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, Chetter I, Diamantopoulos A, Ganeshan A, Hall J, Hobbs S, Houlind K, Jarrett H, Lockyer S, Malmstedt J, Patel JV, Patel S, Rashid ST, Saratzis A, Slinn G, Scott JA, Zayed H, Deeks JJ. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. Lancet 2023;401:1798-1809.
- Faber A, Menard MT, Conte MS, Kaufman JA, Powell RJ, Choudry NK, Hamza TH, Assmann SF, Creager MA, Cziraky MJ, Dake MD, Jaff MR, Reid D, Siami FS, Sopko G, White CJ, van Over M, Strong MB, Villarreal MF, McKean M, Azene E, Azarbal A, Barleben A, Chew DK, Calvijo LC, Douville Y, Findeiss Y, Garg N, Gasper W, Giles KA, Goodney PA, Hawkins BM, Herman CR, Kalish JA, Koopmann MC, Laskowski IA, Hertado-Mena C, Montaganahalli R, Rowe VL, Schanzer A, Schneider PA, Siracuse JJ, Venermo M, Rosenfeld K. Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia. N Engl J Med. 2022; 387(25):2305-2316.