Peripheral arterial occlusive disease of the lower limbs at public hospitals of Salvador - patients and medical care
(Portuguese PDF version)

João Luiz Barbosa Nunes1, Celi Santos Andrade4, Annibal Muniz Silvany Neto3, Bruno Campos Duque4, Fernanda Pita Mendes da Costa4, Elizabeth Santana dos Santos4, Fábio Mesquita Paes4 , José Siqueira de Araújo Filho2

1. Vascular surgeon and professor, Residency in Vascular Surgery, Hospital Roberto Santos, Salvador, Bahia.
2. Assistant professor, Department of Surgery, School of Medicine, Universidade Federal da Bahia.
3. Associate professor, Department of Preventive Medicine, School of Medicine, Universidade Federal da Bahia.
4. Undergraduate students, School of Medicine, Universidade Federal da Bahia.

Correspondence:
Dr. Annibal Muniz Silvany Neto
Av. Reitor Miguel Calmon, s/n
Faculdade de Medicina da UFBA - Campus Universitário do Canela
CEP 40112-900 - Salvador - BA
Tel.: +55 71 245 8562/245 8551/245 0739
E-mail: silvanyn@ufba.br

ABSTRACT

Objectives: To describe patients with peripheral arterial occlusive disease of the lower limbs who sought medical care at public hospitals in Salvador, state of Bahia, Brazil. The service provided at the hospitals is also described.

Methods: A case-series study was performed. Peripheral arterial disease of the lower limbs was defined according to the following symptoms: absence of distal pulses associated with rest pain and/or trophic lesion. Patients who received medical care at five public hospitals of Salvador between March 2000 and August 2001 were followed up to hospital discharge. Clinical and epidemiological variables were collected for descriptive purposes. We studied 184 patients. The mean age was 69.8 11.3 years. More than half of the patients (52.7%) were males. Approximately 35% came from Salvador and 64.8% came from other cities in the state of Bahia. Urgent or elective patients were included.

Results: At the first medical visit, 72.6% of the patients presented lesion. Twenty-two percent did not mention any treatment during the primary care. Almost all patients (96.2%) presented lesion when arriving at a tertiary health care facility. More than 47.0% were not submitted to angiography. The mean time interval between the request and the performance of angiography was 16.3 days. The incidence of primary amputation was 58.1% and the incidence of arterial revascularization was 29.3%.

Conclusions: Medical care offered to patients with peripheral arterial occlusive disease of the lower limbs at primary and tertiary health care facilities needs to be improved. A reduction in the time interval between the request and the performance of basic procedures that are necessary to obtain efficient care would decrease the number of primary amputations and increase the number of arterial revascularizations.

Key words: epidemiology, amputation, angiography, revascularization.
Palavras-chave: epidemiologia, amputação, arteriografia, revascularização.

J Vasc Br 2002;1(3):201-06

INTRODUCTION

Peripheral occlusive arterial disease (POAD) of the lower limbs affects a great number of patients, causing considerable human suffering and economic loss.1,2 During the last decades, the incidence of lower limb amputations has increased in western countries and should aggravate even more with the extension of life expectancy.3

Few data are available on the characteristics of health care and on the profile of patients in developing countries.4,5 Even in industrialized countries, such as Holland and Germany, information on the referral and follow-up of patients with amputated lower limbs is limited.6,7 In Germany, below-knee amputations account for 68.9% of all amputations.7

Although the benefits offered by revascularization, when compared to primary amputation, in terms of socioeconomic aspects and the quality of life of the patient.1,2,8 have been widely established, a large number of patients might not have the opportunity to undergo this procedure due to several factors, such as delayed diagnosis, inadequate referral, and impossibility of having an arteriography performed.

The aim of this study was to describe the profile of the population with POAD of the lower limbs caused by atherosclerosis treated at public tertiary hospitals in the city of Salvador, Bahia, and also to observe health care characteristics up to the moment the patient was discharged from hospital.

METHODS

A case-series study was carried out, including patients treated at five public tertiary hospitals in the city of Salvador, state of Bahia, who sought medical care between March 29, 2000 and August 14, 2001 due to POAD of the lower limbs.

Patients with no distal pulses (posterior tibial and dorsalis pedis) associated with rest pain and/or trophic lesion9,10 were diagnosed with POAD. Cases with inflammatory arterial disease, acute arterial occlusion, aneurysm, trauma, aortic dissection, and with previous treatment or revascularization were not included. The latter were not included due to the possibility of their receiving a differentiated treatment because of previous medical care.

The inclusion of patients in the study was done progressively during data collection. The follow-up time varied according to the outcome of patients up to their discharge. The outcomes considered were: revascularization, amputation, hospital discharge (as a result of clinical improvement or family request), transfer to another hospital, or death. Patients with different types of amputation had only the most severe form recorded. Patients in the immediate postoperative period of revascularization surgery, even suffering amputation later on, were classified as revascularized patients, since the aim was not to evaluate graft success, but rather the probability of the patient being revascularized.

Six medical students were trained and supervised for correct and standardized identification of the diagnosis, interviews, and collection of data to be included in medical records. The patients themselves were the respondents or, whenever necessary, the persons who accompanied them. Each student was in charge of data collection at one hospital, except for one of the hospitals, which was much sought-after, and consequently required two students for data collection. At least once a week, the student in charge went to the hospital, headed to the general or vascular surgery ward or to the emergency department, where he examined the patients for diagnosis. When POAD was detected, the patients or persons accompanying them were interviewed and from that moment on the case was followed up by reference to the medical records in subsequent instances, until any of the outcomes mentioned above occurred.

The questionnaire used for standardized interviews and data collection consisted of three parts: identification and general information (name, gender, age, hospital, registry number and origin), information about primary care (time elapsed before treatment, clinical status, treatment used) and tertiary care information (access to a vascular surgeon, presence of diabetes mellitus, ASA anesthetic risk classification,11 exams performed, outcome, level of amputation).

The present study focused on the description of the variables studied by the calculation of simple, relative, and accumulated frequencies, means, standard deviations, and plotting the data (histograms, sector, box, stem and leaf diagrams). Cumulative incidence was used as measure of frequency, since using the calculation of person-time was not advisable as none of the analyzed characteristics could change classifications due to the short follow-up time or to its unchangeable nature, as in the case of the gender variable.

This study was approved by the Ethics and Research Committee of Hospital Universitário Professor Edgard Santos.
The study population included 184 patients, and information on outcome was available for 167 of them. The mean age was 69.8 + ou - 11.3 years. More than half (52.7%) of the patients were males, with a mean age of 68.5 + ou -11.7 years; 47.3% were females, with mean age of 71.2 + ou - 10.6 years. In diabetic patients, the mean age was 67.7 + ou - 10.5 years, and in nondiabetic patients, it was 72.5 + ou - 11.9 years. More than thirty-five percent of the patients (35.2%) of the patients were from Salvador and 64.8% from other cities or towns in the state of Bahia. Some results do not include all the studied patients due to the fact that some information could not be obtained.

RESULTS

Characteristics of primary care

Table 1 shows that 73.3% of the patients reported the onset of symptoms more than 45 days before primary care. Considering the moment of the interview carried out in this study, 55.2% of the patients had sought medical care more than 45 days before.

click hereTable 1 - Some general characteristics of patients and medical care

Characteristic
n
%
Onset of symptoms
Over 45 days 132 73.3
45 days or less 48 26.7
Search for primary care
Over 45 days 96 55.2
45 days or less 78 44.8

 

Primary care was given at hospitals for 56.3% of the patients, at a private clinic for 21.5%, at a health center for 20.3%, and in other locations for the remaining patients (Table 2).

click hereTable 2 - Characteristics of primary care

Characteristic
n
%
Place where care was provided
Hospital
 89 56.3
Health center
 32 20.3
Private clinic
 34 21.5
Other
 03 1.9
Medical specialty
Clinical medicine
 74 53.2
General surgery
 22 15.8
Angiology
 20 14.4
Other
 23 16.6
Clinical status
With trophic lesion
 130 72.6
Without trophic lesion
 49 27.4
Treatment
Yes
 117 78.0
With trophic lesion
 83

70.9
Without trophic lesion
 34 29.1
No
 33 22.0
Transfer to tertiary hospital according to medical recommendation
Yes
 141 81.5
No
 32 18.5

 

Table 2 shows that the medical specialty in charge of the care was clinical medicine in 53.2% of the cases, general surgery in15.8%, angiology in14.4%, and other specialties in 16.6%. Nineteen percent of the patients did not know which medical specialty was in charge of their care. As to the clinical status of patients by the first medical visit, 72.6% had trophic lesion. Twenty-two percent of the patients said they did not receive any type of treatment during primary care, whereas 78.0% were submitted to some kind of clinical treatment. Among the latter, 70.9% showed trophic lesion at the time of primary care.

The transfer to a tertiary care hospital occurred by means of medical recommendation in 81.5% of the patients and by the patient's own choice in 18.5%.

Characteristics of tertiary care

On admission to the tertiary care hospital, 96.2% of the patients showed some kind of lesion. Of the total number of patients, 47.5% had lesions on their fingers, 38.3% on their feet and 10.4% on their legs (Table 3).

click hereTable 3 - Characteristics of tertiary care

Characteristic
n
%
Presence of lesion at hospital admission
Finger lesion
 87 47.5
Foot lesion
 70 38.3
Leg lesion
 19 10.4
No lesion
 07 3.8
Acess to a vascular surgeon
Yes
178 96.7
No
 06 3.3
     
Documented pulse
Yes
154 84.2
No
 29 15.8
Pressure measurement with Doppler ultrasound registered in themedical record
Yes
 14 8.2
No
 157 91.8
Duplex scanning
Yes
14 8,2
No
 157 91.8
Arteriography
Yes
 94 52.8
No
 84

47.2

 

Table 3 also shows that only 3.3% of the 184 patients admitted to a tertiary hospital did not have access to a vascular surgeon, and that the mean waiting time for those who had access to a vascular surgeon was 2.2 days. More than 84% of the patients had their pulse rates documented and recorded in some hospital registry.

We also observed that 12.1% (22/182) of the patients were bedridden and 9.2% (17/184) had ankylosis of the knee.
Based on the stratification of ASA anesthetic risk, 78.3% (n = 144) of the patients were placed in categories 1, 2 or 3, and 21.7% (n = 40) in categories 4 or 5.

The proportion of diabetic patients was 57.9% (103/178).

According to hospital registries, 37.4% of the patients did not have their extremity pressures measured by Doppler ultrasound (Table 3).

A duplex scan of the lower limbs was not requested in 87.7% (150/171) of the patients; it was only requested in 12.3% (21/171) of the cases. Among the patients for whom a duplex scan of the lower limbs was requested, 66.6% were submitted to the exam, which corresponds to 8.2% of the total (Table 3).

More than 47.0% of the patients were not submitted to arteriography (Table 3). Nineteen patients had been submitted to arteriography before hospital admission, and among the remaining 159 patients, arteriography was requested for 74.2% (n = 118) and not requested for 25.8% (n = 41). Of the patients for whom the exam was requested, 43 (36.5%) did not have it done. The mean time interval between the request and carrying out of arteriography was 16.3 days. Of the 41 patients without a request for arteriography, 46.3% (n = 19) had one of the following conditions: were bedridden, had ankylosis of the knee, had extensive lesion on the leg or were included in groups 4 or 5 of the ASA anesthetic risk classification.

Revascularization was requested for 55.3% (94/170) patients and not requested for 44.7% (76/170). Among the former ones, 45.6% (n = 41) were not submitted to any revascularization attempt, and 54.4% (n = 49) had actually at least one attempt in a mean time of 32.7 days after hospital admission.

Amputation at any level was requested for 62.3% (109/175) of the patients, either due to primary recommendation or to impossibility of revascularization. Of the patients with a request for amputation, 89.0% (n = 97) were submitted to primary amputation on average 24.3 days after hospital admission, and 11.0% (n = 12) did not have it done.

Of the 97 amputations carried out, 74.2% (n = 72) were regarded as large amputations, 43.3% (n = 42) of which were performed at the thigh and 30.9% (n = 30) at the leg. Nearly 26% (25.8%; n = 25) consisted of small amputations, distributed as follows: 16.5% (n = 16) at the finger and 9.3% (n = 9) at the forefoot. More than 21% (21.6%; n = 21) of the patients were initially submitted to open guillotine until the definitive level was achieved.

In the 167 patients followed up to outcome, the incidence of primary amputation was 58.1% (n = 97) and incidence of revascularization was 29.3% (n = 49). Over 12% (12.6%; n = 21) were not submitted to any kind of procedure because they were discharged, transferred to another hospital or died.

Among the 98 diabetic patients, 28.6% (n = 28) were submitted to revascularization attempts. The incidence of primary amputation among these patients was higher (62.2%; n = 61) than that obtained for nondiabetic patients (51.5%; 35/68).

DISCUSSION

Vascular surgery has several diagnostic and therapeutic resources for POAD of the lower limbs; however, technological and scientific advances are not fully available to the population at large.12 Many aspects may delay or even preclude specialized treatment. Very likely, the population's lack of information on vascular diseases contributes to delayed medical care. The difficult access to medical care, as suggested by the study results, may stem from failures in the referral and counter-referral of patients. We observed that first care was not given, in most cases, at primary care facilities, as recommended by the current public health policies. It is also possible that the difficulty of a nonspecialist in identifying patients with POAD at an early time results in delayed referral of these patients to more complex levels of medical care, which was suggested in this study by the remarkable increase in the number of patients who presented trophic lesion between first care and admission to a tertiary hospital, and by the excessive time elapsed between first care and hospital admission. Tertiary hospitals in Salvador, capital of the state of Bahia, have a huge demand of patients, which ends up affecting the efficiency of treatment. This was observed through the great number of patients from other cities in the state of Bahia, delayed assessment by a vascular surgeon, delayed carrying out of specific exams, and the large number of patients who were not submitted to any kind of surgical treatment during hospitalization.

Many specific exams are requested but are not carried out due to the different infrastructure conditions that hinder the full activity of medical specialties. Arteriography is performed at only two hospitals, and duplex scanning in only one. The small number of patients that manage to be submitted to a revascularization attempt after a long hospital stay, and the high number of primary amputations suggest that population's lack of information, difficult access to primary care, lack of early diagnosis, centralization of tertiary care and difficult carrying out of specific exams incur in higher costs for the Health System and a worse prognosis for patients with POAD of the lower limbs.1,2,11,13

The target population consisted of patients with POAD of the lower limbs treated since the creation of Vascular Surgery Services in the surveyed hospitals and those patients still to be treated. However, the patients analyzed were those admitted during a specific period of data collection, and they cannot be regarded as representative of patients previously treated in the surveyed hospitals, since there might have been significant improvements in the services of vascular surgery, with impact on the investigated reality. Thus, after studying the patients during approximately one year and four months, the obtained results are valid only for this specific period. As to the patients to be treated in the future, the studied sample may be representative until the moment important changes occur to the profile of the patients and to the medical care provided. This way, the present study does not intend to generalize its results to previously treated patients, and as the generalization to patients to be treated is conditional, we preferred to assume that the results of the study will be regarded as valid only for the patients admitted during the data collection period. Since all patients with POAD of the lower limbs diagnosed at the five hospitals analyzed during the data collection period were included in the study, we considered there was no sampling and therefore statistical inference tests were not carried out, as such procedures lost their purpose in the present study.

CONCLUSIONS

Primary and tertiary medical care to patients with POAD of the lower limbs at the health units comprised by the present study has to be improved. Such improvement should be aimed at: reduction of average time between fundamental procedures for efficient patient care; availability of essential exams to all patients for a detailed diagnostic investigation; reduction of primary amputations; and increase in the number of revascularizations.

ACKNOWLEDGMENTS

Thanks to Professor Ines Lessa, who helped us with the initial study plan. Also thanks to Dr. Andressa Barreto Fascio for revising the text in Portuguese.

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J Vasc Br - Official Publication of the Brazilian Society of Angiology and Vascular Surgery