Mortality and morbidity risk factors in patients with critical limb ischemia

Dear Editor,

We have read the article by Altunova et al. 1 entitled “The relationship between hyperpolypharmacy and one-year outcomes in patients with critical limb ischemia undergoing below-knee endovascular therapy” with great interest. First of all, we congratulate the authors for their contribution. However, we would like to discuss some points about the worse outcomes in patients with critical limb ischemia (CLI).

The 5-year all-cause mortality rates of patients diagnosed with CLI are higher than many cancer diseases. Apart from this situation, limb loss also appears as an important morbidity reason. ² In the current study, 200 consecutive patients diagnosed with CLI who received endovascular treatment were analyzed retrospectively, and hyperpolypharmacy was identified as an important risk factor for mortality and amputation in 1-year follow-up. ¹ Was endovascular intervention successful in all patients? Was surgery required in any patient? We think that clarifying this situation is important for a study investigating amputation risk. Additionally, was angiographic imaging of both lower extremities, including the infrarenal abdominal aorta, performed in the patient group? The extent of disease in these segments may affect clinical outcomes. ³ The authors excluded patients with a previous history of revascularization to the same vascular bed. It should not be forgotten that interventions performed on other arterial segments may also affect clinical results.

Although angiographic imaging is an important evaluation tool in the presence of CLI, it may not always correlate with tissue perfusion. For this reason, we think that ankle-brachial index (ABI) measurements are important in these patients. ⁴ Additionally, various factors other than ABI could provide valuable information about tissue perfusion.^5,6

Patients with peripheral artery disease have a high risk of cardiovascular death. The risk increases even more when these patients have CLI. The risk of stroke and myocardial infarction is equivalent to that of patients with coronary artery disease. ⁷ For these reasons, detailed imaging of the coronary and carotid artery systems in these patients may be useful in predicting prognosis.

Finally, hyperpolypharmacy may be a sign of the presence of additional comorbid diseases. This may also affect mortality. However, while predicting the risk of amputation, factors such as the condition of the distal vascular bed and the technical success of endovascular intervention may be more prominent. In mortality analysis, diagnostic evaluation of the cerebral and coronary systems could be made in more detail.