Association of Referring Specialty With Limb Loss in Chronic Limb-Threatening Ischemia

Objective Chronic limb-threatening ischemia (CLTI) is associated with high morbidity and mortality. While delayed referral is known to worsen outcomes, the impact of referring specialty remains unclear. This study evaluates whether different referral sources to vascular surgery impact mortality and major amputation rates. Methods A retrospective review was conducted of patients referred to vascular surgery for CLTI at a single institution (2021-2022). The outcomes investigated were mortality, amputation and composite freedom from amputation or mortality (amputation free survival). Univariable analysis was first conducted followed by multivariable Cox regression utilizing variables which had a univariable P value of <0.1 for the outcomes. Results Among 132 patients, 19.7% died and 19.7% underwent major amputation. Mean duration of follow up for included patients was 1471 days (4.03 years). Congestive heart failure (CHF) independently predicted mortality (HR 3.86, P = .0114) on multivariable analysis. Chronic kidney disease (CKD), gangrene, and non-healing wounds were associated with amputation on univariable analysis ( P < .05). Referral from emergency medicine had multivariable association with higher amputation rates, while podiatry referral demonstrated a protective effect (HR 0.28, P = .0472). Referral from emergency medicine had multivariable association with reduced amputation free survival relative to all other specialties combined (HR 2.953 (1.66-5.26), P < .001) and relative to other specialties individually ( P = .0023). Conclusions Outcomes in CLTI are associated with variations in both comorbidities and referral patterns. Earlier, multidisciplinary referral pathways may improve limb salvage as patients with CLTI referred from emergency have higher amputation rates and reduced amputation free survival.