Two-year Mortality in CLTI Patients Provide Crucial Factors We Should Fight.

As mentioned by Hata et al. [1)] , 2-year mortality in patients with chronic limb-threatening ischemia (CLTI) is an important factor for understanding the management of CLTI. In the 2007 Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial [2)] , it was reported that bypass surgery is appropriate as first-line revascularization if CLTI patients have durable veins and an expected life expectancy of ＞2 years. Additionally, the European Society of Cardiology guidelines [3)] and the 2005 American College of Cardiology Foundation/American Heart Association updated guidelines [4)] were revised to indicate that life expectancy of ＞2 years is an important factor for the initial revascularization in CLTI patients. However, this concept is extremely limited because there is no obvious definition of 2-year life expectancy. Furthermore, the evidence regarding Japanese CLTI patients is insufficient to apply in a clinical setting. Therefore, it is considered that the risk stratification for 2-year mortality and causes of death in CLTI patients, as Hata stated, is helpful to predict a 2-year life expectancy.

Furthermore, it is very interesting that the prognosis of CLTI patients is extremely poor even after successful revascularization. Although successful revascularization is required to achieve wound healing, it does not have any effect on mortality. Thus, the following question arises: what approaches should we adopt to improve mortality as well as wound healing? From Hata’s study, we learn risk stratification and causes of death. AS per the study, two-thirds of the CLTI patients were dead due to infectious diseases and cardiovascular (CV) events. These two main causes of death in CLTI patients, as mentioned in the study, provide us with knowledge on the correct management of the CLTI treatment. We can divide the two causes of death into the two following treatment phases: acute and chronic. In the acute phase, the first battle against infectious diseases begins. To achieve complete wound healing, it is important to administer broad antibiotics, in addition to adequate debridement and minor amputation, to control the infection. During wound care, contracting an infectious disease such as sepsis can often be lethal. Especially, after successful revascularization, the risk of sepsis increases because of the spread of the closed focal infection.

If we can overcome this first battle, we have to deal with the oncoming second battle, which is against CV events. Most CLTI patients have severe atherosclerotic change in almost all arteries, such as coronary artery, cerebrovascular artery, carotid artery, mesenteric artery, and lower extremities’ artery. It is important to note that revascularization of the index limb is the focal treatment of progressive systemic atherosclerosis. Therefore, optimal medical therapy (antiplatelet drug, statin, etc.) should be considered.

Finally, this article presents factors involved in the treatment of CLTI. It is not equal to wound management alone. For improvement in the outcomes—in both the aspects of leg and life—of CLTI patients, the estimate and management of infection and CV events in addition to ordinal wound care is needed. Further investigation and data accumulation are required to verify these findings. Despite several limitations, as mentioned by Hata, the present study provides an accurate direction for Japanese CLTI management, which has few established evidences.

Conflicts of Interest

None.