Search

A study was undertaken to derive specific indications for surgery in patients with chronic critical lower limb ischaemia, and to determine the extent to which practice throughout Scotland conformed with these indications. Consensus methods provide an explicit and systematic method of deriving indications from published evidence and clinical experience. A review was undertaken of the published literature on outcomes following arterial reconstruction and primary major amputation, in terms of life-expectancy, limb-salvage, healing, reoperation, social and physical functioning, quality of life and cost-effectiveness. Thereafter, consensus indications were agreed using a modified Delphi method in which a postal questionnaire was completed by 29 vascular surgeons on two occasions, with feedback between the rounds. This method has been used previously to develop indications for coronary artery bypass grafting and carotid endarterectomy. Use of a postal questionnaire avoids physical constraints on the selection of panellists, whilst also ensuring that undue weight is not given to the most dominant or vocal participants. Respondents indicated the appropriateness of arterial reconstruction and primary major amputation for 218 case-scenarios comprising all possible combinations of clinical and angiographic findings. Agreement was reached on 31 appropriate indications for major amputation and 65 for arterial reconstruction. The consensus indications were then compared with actual clinical practice in a stratified random sample of ten Scottish hospitals. Four hundred primary major amputations and arterial reconstruction operations were reviewed retrospectively. The clinical findings for 7 (4%) arterial reconstruction operations and 48 (24%) major amputations did not conform to the indications agreed by the Delphi method. The proportion of operations conforming to the agreed indications differed significantly by size of unit (p<0.05). The study demonstrated that consensus could be reached on indications for surgery in patients with chronic critical lower limb ischaemia. The proportion of procedures conforming to the indications varied between units, suggesting that differences in clinical decision-making were apparent.