The global burden of CLTI: ESVS President points toward need for new global vascular guidelines

Asha Malan, Palma Shaw, Philippe Kolh

Early-bird VAM 2023 attendees yesterday gained broad insight into the issues facing vascular surgeons around the world, with the tone set from the opening talk on the World Federation of Vascular Societies (WFVS) Educational Session docket.

Looking at the global burden of chronic limb-threatening ischemia (CLTI) and the joint guidelines that steer practice, Philippe Kolh, MD, from the University Hospital of Liege in Belgium and current president of both the European Society for Vascular Surgery (ESVS) and the WFVS, told attendees: “We need a new version of these guidelines.”

Kolh was talking through the global burden, patterns and management of CLTI patients across the globe. He set the scene for the core argument behind his message on what the latest survey data show. “The caseload is highly variable,” he said.

“The proportion of CLTI patients need­ing primary amputation was very large across centers, with the lowest proportion in the U.S. and the highest in India and South Africa—that probably also reflects the type of care that we can provide to our patients with CLTI.

“In Asia and South Africa, the majority use the GLASS [the Global Limb Anatomic Staging System] rating; in other regions, the minority of the reporting centers use GLASS.

“A similar pattern (and discrepancy) was seen with the risk calculator: the majority in Asia and South Africa use it. The WIfI (Wound, ischemia and foot infection) system is used by the majority in most countries except, quite strangely, the U.S., where 50% of centers reported no use of WIfI.”

Assessing how much is this snapshot representative of the global picture, Kolh proffered. “We’ll see in the next survey,” he said.

“Endovascular-first strategy was the most common strategy in India and South Africa. In other countries, the majority reported that endovascular-first is not their approach for CLTI.

“For bypass surgery, in addition to great saphenous vein [GSV], synthetic graft is the preferred conduit in many centers, while for below-the-knee bypass with a GSV is preferred.

When there was no GSV, the contralat­eral vein was the preferred conduit in all countries when above-the-knee bypass is in question. When below-the-knee bypass is needed in cases of no conduit, surprisingly [an] endovascular approach is the most preferred alternative. No center reported arm veins as an option.”

Further, said Kolh, drug-eluting technol­ogy is accepted in both femoropopliteal and crural artery segments, and arm veins are used in about 40% of centers.

He then turned to costs. “There was a huge variation in procedural cost across countries and centers,” Kolh reported. “The percentage of patients who bear out-of-pocket [costs] is quite different. It varies from less than 10% [in the majority of centers] to up to 80% [in India/Asia].”

Meanwhile, Kolh provided feedback based upon the impact of the BEST-CLI (Best endovascular vs. best surgical therapy in patients with critical limb ischemia) trial, and how it had altered surgeon practice. “About half of replies indicate that the BEST-CLI trial has changed their practice,” he revealed. “If the answer was ‘no,’ the reason most often given was that they already were doing their practice according to the results.”

Concluding, Kolh said there was “huge variation” in patterns of CLTI treatment across the globe.

The WFVS session—the second to be hosted at VAM—saw each member society of the organization represented in person, said moderator Palma Shaw, MD, the WFVS secretary-general.

One of those—the Vascular Society of Southern Africa (VASSA)—produced an insight on the state of vascular surgery training in Africa, and the challenges faced on the continent.

Asha Malan, MD, a VASSA executive committee member, provided stark data. The South African population of approx­imately 60 million is currently served by nearly 65 [vascular surgeons]—“even though this does reflect an approximate 50% increase over the last decade.”

This compares to France, with a similar population of 67 million, where there are 10 times this number of vascular surgeons, she said. “To make matters worse,” Malan went on, of that 65 number, “only 13 of us are currently employed in the public sector, carrying 80% of the burden of disease.”

Because of the shortage of general surgeons in South Africa, vascular surgery is still considered a subspecialty of general surgery, she said, with the consequence that vascular surgery training requires a further two years after five years of general surgery training completion.

Training is offered at seven centers, Malan added, with a currently enrolled rate of 14 trainees. “However, due to the lack of funding for training programs,” just two-to-four vascular surgeons qualify annually, resulting in a net loss, she pointed out.

“South Africa needs to re-evaluate the need for revision of specialized vascular surgical care,” Malan concluded.


Please enter your comment!
Please enter your name here