LAUSR

Dear Editor We read with interest the article entitled “The Monocyte/ High Density Lipoprotein Cholesterol Ratio (MHR) as an Indicator of the Need for Amputation in Patients with Peripheral Artery Disease Developing Critical Limb Ischemia (CLI)”. We congratulate the authors for their valuable contribution. Monocytes play an important role in the formation of atherosclerotic plaque and high density lipoprotein cholesterol may exert protective effects. However, we would like to consider some factors affecting amputation rates in patients with peripheral arterial disease (PAD). The authors investigated the role of the MHR on amputation in patients with PAD. They included 563 patients with PAD divided into 2 groups: those who developed CLI and underwent an amputation (n = 226) and those who underwent surgical or endovascular revascularization and were medically followed up due to PAD (n = 337). The data of the amputated patient group in this study were obtained from the orthopedics clinic. Did these patients previously undergo peripheral intervention? If so, how many times? Or why was no intervention performed? Also, the authors stated that all patients underwent lower extremity computed tomography or catheter angiography. Was the Trans-Atlantic Inter-Society Consensus II (TASC-II) classification used? Were the patients in the amputation group not treated because they had severe belowknee disease? Patients with advanced TASC-II will have an increased risk of amputation. The authors found no difference in medical treatments (aspirin, clopidogrel, cilostazol, statin) between the 2 groups. Was iloprost used? Iloprost administration can be protective for limb ischemia and is used in our clinic for patients with CLI. In addition, the authors excluded patients with diabetic feet. However, the rate of diabetes mellitus was 27.3% in patients with amputation and 20.1% in patients who did not undergo amputation (P = .012). How was it determined that these patients did not have diabetic feet? In conclusion, the MHR is associated with the development and prognosis of atherosclerotic disease. However, the absence of TASC-II classification (iliac, femoral, below-knee) in the multivariate analysis and the lack of elucidation of the PAD history of the amputation group may be misleading.