Basic data related to amputations

Chronic kidney disease predicts long-term mortality after major lower extremity amputation

Background:

Despite low peri-operative mortality after major lower extremity amputation, long-term mortality remains substantial. Metabolic syndrome is increasing in incidence and prevalence at an alarming rate in the USA.

Aim:

This study was to determine whether metabolic syndrome predicts outcome after major lower extremity amputation.

Patients and Methods:

A retrospective review of charts between July 2005 and June 2010.

Results:

Fifty-four patients underwent a total of 60 major lower extremity amputations. Sixty percent underwent below-knee amputation and 40% underwent above-knee amputation. The 30-day mortality was 7% with no difference in level (below-knee amputation, 8%; above-knee amputation, 4%; P = 0.53). The mean follow-up time was 39.7 months. The 5-year survival was 54% in the whole group, and was independent of level of amputation (P = 0.24) or urgency of the procedure (P = 0.51). Survival was significantly decreased by the presence of underlying chronic kidney disease (P = 0.04) but not by other comorbidities (history of myocardial infarction, P = 0.79; metabolic syndrome, P = 0.64; diabetes mellitus, P = 0.56).

Conclusion:

Metabolic syndrome is not associated with increased risk of adverse outcomes after lower extremity amputation. However, patients with chronic kidney disease constitute a sub-group of patients at higher risk of postoperative long-term mortality and may be a group to target for intervention.

Peripheral arterial disease of the lower extremities

Persons with peripheral arterial disease (PAD) are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Smoking should be stopped and hypertension, dyslipidemia, diabetes mellitus, and hypothyroidism treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. The serum low-density lipoprotein cholesterol should be reduced to < 70 mg/dl. Antiplatelet drugs such as aspirin or clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to persons with PAD. β-Blockers should be given if coronary artery disease is present. Cilostazol improves exercise time until intermittent claudication. Exercise rehabilitation programs should be used. Revascularization should be performed if indicated.

Peripheral arterial disease in women

Peripheral arterial disease (PAD) is chronic arterial occlusive disease of the lower extremities caused by atherosclerosis whose prevalence increases with age. Only one-half of women with PAD are symptomatic. Symptomatic and asymptomatic women with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from coronary artery disease. Modifiable risk factors that predispose women to PAD include active cigarette smoking, passive smoking, diabetes mellitus, hypertension, dyslipidemia, increased plasma homocysteine levels and hypothyroidism. With regard to management, women who smoke should be encouraged to quit and referred to a smoking cessation program. Hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism require treatment. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in women with PAD and hypercholesterolemia. Anti-platelet drugs such as aspirin or especially clopidogrel, angiotensin-converting enzyme inhibitors and statins should be given to all women with PAD. Beta blockers are recommended if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided as it is ineffective. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery in women are (1) incapacitating claudication interfering with work or lifestyle; and (2) limb salvage in women with limb-threatening ischemia as manifested by rest pain, non-healing ulcers, and/or infection or gangrene. Future research includes investigation of mechanisms underlying why women have a higher risk of graft failure and major amputation.

A prospective study examining balance confidence among individuals with lower limb amputation

PURPOSE

In this study we assessed whether balance confidence scores changed over a 2-year follow up period, and identified predictors of balance confidence and predictors of change in balance confidence among lower limb amputees.

METHOD

A prospective follow-up survey of 245 community living adults with unilateral below and above knee lower limb amputation who used their prosthetic limb daily was conducted. Balance confidence, assessed using the 16-item Activity-specific Balance Confidence (ABC) Scale, socio-demographic, health and amputation related variables were collected at baseline and 2 years later.

RESULTS

ABC scores were similar at baseline (mean = 67.6; SD = 25.7) and follow up (mean = 68.0; SD = 25.8). Lower balance confidence scores at follow up were predicted by older age, being female, use of a mobility device, poor perceived health, increased symptoms of depression, having to concentrate while walking, and fear of falling (all p < 0.05). Predictors of change in balance confidence included gender and perceived health (all p < 0.05).

CONCLUSION

Balance confidence appears to be a persistent problem in the amputee population. Health professionals are encouraged to consider balance confidence as a potentially important variable that may influence function in this clinically unique group of individuals. The identified predictor variables may be useful to clinicians in targeting individuals who require attention to improve balance confidence.

Management of peripheral arterial disease of the lower extremities

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in patients with peripheral arterial disease (PAD) of the lower extremities. Statins decrease the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all persons with PAD. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in persons interfering with work or lifestyle, (2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene, and (3) vasculogenic impotence.

A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization

In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.

Survival and quality of life after arterial revascularization or major amputation for critical leg ischemia in Guadeloupe

Functional outcome and survival in 253 patients treated for critical leg ischemia (CLI) in Guadeloupe (French West Indies) were analyzed. Analysis included calculation of quality-of-life score (QLS) from telephone survey data, with a median follow-up time of 42 months (range 12-109). A slight but significant benefit was observed in the 140 patients who underwent arterial reconstruction, with 76% autonomous ambulatory function, 51% independent residential status, and a QLS of 6.9 +/- 1.5 in comparison with the 113 patients who underwent amputation: 34%, 17%, and 5.1 +/- 2, respectively (p < 0.0001). Survival was comparable in the two groups. Inadequate medical follow-up that was either totally lacking or performed only in case of recurrent CLI as well as low rates of rehabilitation (50%) and prosthetic fitting (32%) in the amputation group highlight the existence of a double problem involving therapeutic compliance and vascular follow-up care/rehabilitation in Guadeloupe.

Peripheral arterial disease in the elderly

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in elderly patients with peripheral arterial disease (PAD) of the lower extremities. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in patients with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all elderly patients with PAD without contraindications to these drugs. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in patients interfering with work or lifestyle; (2) limb salvage in patients with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and (3) vasculogenic impotence.

Outcomes of a contemporary amputation series

BACKGROUND

The aim of this study was to determine the outcomes of a contemporary amputation series.

METHODS

A retrospective audit of 87 cases of major lower limb amputation from January 2000 to December 2002 from the Department of Vascular Surgery, Royal Perth Hospital, was conducted.

RESULTS

The mean age of the study population was 70.1 +/- 14.3 years; the male : female ratio was 3.35:1. Comorbid problems included diabetes (49.4%), smoking (81.6%), hypertension (77.0%), ischaemic heart disease (58.6%), stroke (25.3%), raised creatinine level (34.5%) and chronic airway limitation (25.3%). Preamputation vascular reconstructive procedures were common, 34.5% in a previous admission and 23.0% in the same admission. The main indication was critical limb ischaemia (75.9%) followed by diabetic infection (17.2%). There were 51 below-knee (58.6%), 5 through-knee (5.7%) and 31 above-knee (35.6%.) amputations. The below-knee amputation to above-knee amputation ratio was 1.65:1. The overall wound infection rate was 26.4%; the infection rates for below-knee (29.4%) and above-knee (22.6%) amputation did not differ significantly (P = 0.58). Revision rates were 17.6% for below-knee, 20% for through-knee and none for above-knee amputations. Twenty patients (23.0%) underwent subsequent contralateral amputation. Thirty-nine patients (44.8%) were selected as suitable for a prosthesis by a rehabilitation physician; 31 (79.5%) used the prosthesis both indoors and outdoors and 6 (15.4%) used it indoors only within 3 months. Cumulative mortality at 30 days, 6 months, 12 months and 24 months was 10.1, 28.7, 43.1 and 51.7%, respectively.

CONCLUSION

This series agrees with the current published work in finding that patients undergoing major lower limb amputation are older, with a high prevalence of comorbid conditions. Successful prosthesis rehabilitation depends on patient selection and a multidisciplinary approach. Despite a low immediate mortality, the overall long-term results of lower limb amputation remain dismal.

Racial differences in primary and repeat lower extremity amputation: Results from a multihospital study

OBJECTIVE

African Americans have a much higher risk of major (above- or below-knee) lower extremity amputation and a lower rate of limb-preserving vascular surgery or angioplasty than white patients. This article analyzes two potential pathways for racial disparities: primary amputation, defined as a major amputation performed without any prior attempt at revascularization, and repeat amputation, defined as a major amputation subsequent to a previous through-foot or major amputation.

METHODS

Randomly selected medical records were reviewed for 248 African American, 30 Hispanic, and 235 white or other-race patients undergoing above- or below-knee amputation between 1995 and 2003 at three Chicago teaching hospitals. Chronic disease prevalence and severity, preadmission functional status, clinical presentation, and vascular history were used to test the risk-adjusted effect of race and ethnicity on rates of primary and repeat amputation.

RESULTS

Controlling for demographic, functional, chronic disease, and clinical characteristics, African American patients were 1.7 times more likely to have undergone both primary (P = .01) and repeat (P = .03) amputation than white or other-race amputees. Race remained a significant independent risk factor even after controlling for the higher severity of illness, greater disability, and more complex presentation of African American amputees.

CONCLUSIONS

Higher rates of primary and repeat amputation for African American patients at study hospitals, which all have significant vascular surgery capacity and an aggressive policy of limb salvage, suggest that these rates may be even higher at less well equipped institutions. Improving access to primary and preventive care for lower-income patients could reduce amputation rates among African Americans.

Management of Peripheral Arterial Disease

Peripheral arterial disease (PAD) may be asymptomatic, may be associated with intermittent claudication, or may be associated with critical limb ischemia. Coronary artery disease (CAD) and other atherosclerotic vascular disorders may coexist with PAD. Persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from CAD. Modifiable risk factors such as cessation of cigarette smoking and control of dyslipidemia, hypertension, and diabetes should be treated. Statins reduce the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, and angiotensin-converting enzyme inhibitors should be given to all persons with PAD. beta-Blockers should be given if CAD is present. Exercise rehabilitation programs and cilostazol improve exercise time until intermittent claudication. Indications for lower-extremity angioplasty, preferably with stenting, or bypass surgery are 1) incapacitating claudication in persons interfering with work or lifestyle; 2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and 3) vasculogenic impotence. However, amputation should be performed if tissue loss has progressed beyond the point of salvage, if surgery is too risky, if life expectancy is very low, or if functional limitations diminish the benefit of limb salvage.

Management of Peripheral Arterial Disease of the Lower Extremities in Elderly Patients

The prevalence of peripheral arterial disease (PAD) increases with age. PAD in elderly persons may be asymptomatic, may be associated with intermittent claudication, or may be associated with critical limb ischemia. Other atherosclerotic vascular disorders, especially coronary artery disease (CAD), may coexist with PAD. Elderly persons with PAD are at increased risk for all-cause mortality, cardiovascular mortality, and mortality from CAD. Modifiable risk factors should be treated in persons with PAD such as cessation of cigarette smoking and control of hypertension, dyslipidemia, and diabetes. Statins have been shown to reduce the incidence of intermittent claudication and to improve treadmill exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, should be administered to all persons with PAD. Persons with PAD should be treated with angiotensin-converting enzyme inhibitors and also with beta blockers if CAD is present. Cilostazol should be given to persons with intermittent claudication to improve exercise capacity unless heart failure is present. Exercise rehabilitation programs improve exercise time until claudication. Indications for lower extremity angioplasty, preferably with stenting, or bypass surgery are 1) incapacitating claudication in persons interfering with work or lifestyle; 2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene; and 3) vasculogenic impotence. However, amputation should be performed if tissue loss has progressed beyond the point of salvage, if surgery is too risky, if life expectancy is very low, or if functional limitations obviate the benefit of limb salvage.

Process of care and outcomes in peripheral arterial disease

Peripheral arterial disease (PAD) is a prevalent illness that most commonly affects patients older than 60 years. As the population ages, the prevalence of PAD and its associated adverse outcomes will also increase. Adverse outcomes in PAD are either systemic (ie, cardiovascular events such as myocardial infarctions or strokes) or localized to the legs (ie, bypass surgery or amputation). Although much research has focused on adverse systemic outcomes in patients with PAD, less is known about those factors related to adverse limb events. The Centers for Disease Control and Prevention estimate that more than 100,000 amputations are performed in the United States each year. What remains to be determined is the association between how physicians manage patients with PAD (ie, process of care) and the development of adverse limb outcomes. Determining the association of the management of PAD with adverse limb outcomes will highlight those areas in which to focus to improve the quality of care for patients with this disease. Understanding the relationship between risk factors, process of care, and outcomes will be of importance to patients, clinicians, and policy makers. The purpose of this article is to review the burden of PAD and to discuss the association of process of care with adverse limb outcomes in patients with PAD.

Major lower extremity amputation in an academic vascular center

Major lower extremity amputations continue to be performed despite an aggressive policy of revascularization. Factors leading to amputation were analyzed to determine whether a reduction in the limb loss rate is possible. A retrospective analysis of a prospectively maintained vascular registry was performed to identify patients undergoing above-knee amputation (AKA), below-knee amputation (BKA), and lower extremity revascularization (LER) for limb salvage between January 1, 1999 and January 1, 2002. Patient demographics, comorbidities, insurance carriers, and indications for operative intervention were analyzed. Greater than one-half of all major lower extremity amputations are performed in patients who have failed attempts at revascularization or who are not candidates for LER due to anatomic factors. However, one-quarter of eventual amputees present very late to the vascular surgeon with extensive gangrene or infection that precludes limb salvage. Prompt patient referral and treatment may improve outcome in this group of patients. In our study, insurance issues did not appear to affect treatment. Renal failure continues to play a major role in limb loss.

Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor?

OBJECTIVES

To determine if race/ethnicity is independently associated with an increased risk for nontraumatic lower extremity amputation versus lower extremity bypass revascularization among patients with peripheral arterial disease (PAD).

METHODS

Data were analyzed from the National VA Surgical Quality Improvement Program (NSQIP) and from the Veterans Affairs Patient Treatment File (PTF). Race/ethnicity was defined as non-Hispanic white, black, or Hispanic. Variables that were univariately associated (P < or = 0.05) with the outcome of amputation were placed into a multiple logistic regression model to determine independent predictors for the dependent variable, lower extremity amputation versus lower extremity bypass revascularization.

RESULTS

Three thousand eighty-five lower extremity amputations and 8409 lower extremity bypass operations were identified. Among all cases included, there were 416 Hispanic patients (3.6%), 2337 black patients (20.3%), and 8741 non-Hispanic white patients (76.1%). Among all variables within the model, Hispanic and black race were each associated with a greater risk for amputation than a history of rest pain/gangrene (Hispanic race 1.4, 95% CI 1.1, 1.9; black race 1.5, 95% CI 1.4, 1.7; rest pain/gangrene 1.1, 95% CI 1.0, 1.3). The final model had a c statistic of 0.83.

CONCLUSION

Hispanic race and black race were independent risk factors for lower extremity amputation in patients with PAD. Although the burden of certain atherosclerotic risk factors (eg, diabetes and hypertension) is higher in minority patients, the impact of this burden does not account for the increased risk for the outcome of lower extremity amputation in these two populations. Further research is needed to better understand the reason(s) why race/ethnicity is independently associated with poor outcomes in PAD.

Pedal bypass for limb salvage: impact of diabetes on long-term outcome

Use of pedal bypass can salvage limbs of patients with critical ischemia. The aim of this study was to evaluate the results of surgical revascularization of pedal arteries in diabetic patients and to assess the impact of diabetes on long-term outcome. We performed a retrospective analysis of all consecutive pedal bypasses done between January 1, 1987 and December 31, 1997. Demographic data, surgical indications, operative variables, and postoperative results including graft patency and limb salvage were compared between diabetic and nondiabetic patients. The results of this comparison showed that pedal bypass can safely and effectively relieve critical ischemia in diabetic patients. Diabetics have less early graft thrombosis and superior long-term graft patency. Despite higher incidence of renal insufficiency or failure and more tissue loss, diabetics can achieve similar excellent limb salvage rates. This outcome justifies aggressive revascularization of pedal arteries in diabetic as well as nondiabetic patients with critical limb ischemia.

Major lower extremity amputation in Veterans Affairs medical centers

Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.

Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996

OBJECTIVES

This report describes trends in the rates of lower-extremity amputation and revascularization procedures and vascular disease risk factors.

METHODS

We analyzed trends in National Hospital Discharge Survey data for 1979 through 1996 and in National Health Interview Study data for 1983 through 1994.

RESULTS

Despite a decline between 1983/84 and 1991/92, by 1995/96 the rate of major amputation had increased 10.6% since 1979/80. The earlier 12-year decline was positively correlated with reductions in the prevalence of smoking (r = 0.88, P < .0001), hypertension (r = 0.65, P = .02), and heart disease (r = 0.73, P = .007), but not diabetes (r = -0.33, P = .29). During the 1980s, amputation and angioplasty rates were inversely correlated (r = -0.75, P = .001), but the decline in amputation rates occurred before the increase in angioplasty. The major amputation rate, which has increased since 1993, was 24.95 per 100,000 people in 1996.

CONCLUSIONS

Major amputation rates fell in the years following the diffusion of distal bypass surgery but before the widespread use of peripheral angioplasty. Because disease prevalence and primary amputation rates are unknown, it is difficult to estimate the contribution of recent improvements in vascular surgery to limb preservation.

Long-term outcome after early infrainguinal graft failure

PURPOSE

To determine the long-term outcome and prognostic factors after early infrainguinal graft failure (< 30 days).

METHODS

Retrospective analysis of limb salvage data, patency data, and prognostic risk factors in 112 new infrainguinal bypass grafts from 1985 to 1995 that occluded within 30 days of operation.

RESULT

Thirty-six femoropopliteal and 76 femorotibial/femoropedal arterial bypass ("index") procedures were performed for rest pain (50%), tissue loss (31%), or disabling claudication (19%). In 103 patients, an immediate additional revascularization ("takeback") procedure was performed at the time of early graft failure. Life table analysis of the takeback procedures for threatened limbs (n = 84) revealed limb salvage rates of 74%, 54%, 40%, and 31% at 1 month, 1 year, 3 years, and 5 years, respectively. The 1-month limb salvage rate (threatened limbs) was 12% (1 of 8) in patients who were not taken back for revascularization and 33% (4 of 12) in patients who had undergone more than one takeback procedure within 30 days. The secondary graft patency rates for the takeback procedures (n = 103) were 70%, 37%, 27%, and 23% at 1 month, 1 year, 3 years, and 5 years, respectively. Univariate and life table analysis revealed that patients who were given anticoagulation medication after the index procedure (before graft thrombosis) or patients who had undergone previous ipsilateral leg revascularization had significantly lower rates of limb salvage and graft patency (p < 0.05). The limb salvage rate was also significantly worse in patients who had single-vessel runoff compared with those who had multiple-vessel runoff (p < 0.01). Thrombectomy and revision or complete graft replacement had a better secondary patency rate than thrombectomy alone (p < 0.05). Autogenous vein grafts had better outcome than polytetrafluoroethylene-containing grafts, but statistical significance was not achieved. No significant differences in limb salvage or graft patency rates were found between femoropopliteal versus femorotibial/femoropedal bypass grafting, age, gender, previous inflow surgery, diabetes, hypertension, smoking, or cardiac, renal, or pulmonary disease.

CONCLUSION

The long-term limb salvage and graft patency rates after takeback revascularization procedures for early graft failure are poor. Despite poor outcome, a single takeback procedure appears warranted in all patients. Multiple takeback procedures, however, do not appear to be justified, especially in patients who are given anticoagulation medication after the index bypass procedure, repeat leg bypass procedures, or if there is no potential for graft revision.

Limb loss after lower extremity bypass

BACKGROUND

Infrainguinal bypass now has a limb salvage rate approaching 90% at 10 years. This study helps elucidate the causes of limb loss despite bypass surgery.

METHODS

A retrospective chart review of all patients undergoing a major lower extremity amputation after attempted bypass surgery.

RESULTS

Between July 1987 and January 1997, 67 major amputations (52 below knee, 15 above knee) followed infrainguinal bypass for limb salvage in 64 patients. Of these patients, 53 (83%) were diabetic and 10 (16%) were on dialysis. The etiology of limb loss included thrombosed bypass (n = 33, 49%), lack of limb salvage despite patent bypass (n = 23, 34%), intraoperative bypass failure (n = 6, 9%), and exposed/infected bypass (n = 5, 8%). The 23 patients with patent grafts required amputations because of hindfoot necrosis (n = 6), persistent forefoot necrosis (n = 6), acute diabetic foot infection (n = 6), and various other reasons (n = 5). Using life-table analysis, survival for the whole group was 56% at 12 months and 17% at 48 months. Patients with limb loss despite a patent bypass fared the worst with survival of 21% at 2 years.

CONCLUSIONS

Bypass thrombosis caused half of the amputations after limb salvage surgery. A patent bypass was functioning at the time of amputation in another third. Survival after failure of limb salvage was abysmal, especially in patients with patent bypasses.

Rehabilitation of the older lower limb amputee: a brief review

OBJECTIVE

To review outcomes, over the last 25 to 30 years, of prosthetic rehabilitation in the older patient with a major lower limb amputation.

DESIGN

Literature review of articles and reports about lower limb amputation, using key words elderly amputee rehabilitation, and lower limb amputation, through a computerized Medline Search.

CONCLUSIONS

Age alone should not determine prosthetic rehabilitation. Comorbidities and general health are important determinants. The more proximal the amputation, the more energy is demanded from the cardiovascular and pulmonary systems for prosthetic gait. Changes in surgical technique and revascularization procedures have allowed preservation of the knee, which decreases energy demands and allows more older patients a chance to undergo rehabilitation for ambulation. Although the ratio of below knee (transtibial) amputations to above knee (transfemoral) amputations has increased, overall postsurgical mortality (10-30%), long term survival (40-50%@2 years, 30-40%@5 years), and risk of loss of the contralateral leg (15-20%@2 years) has not changed significantly since the 1960s. Despite the lack of improvement in survival as a result of the systemic vascular disease, the older patient can benefit from rehabilitation efforts with goals of prosthetic ambulation or simply cosmesis. The shortened longevity emphasizes the need for timely rehabilitation to enhance the quality of the remaining years. The geriatrician can add to the presurgical care and preprosthetic phase of rehabilitation by attention to the problems common to the older patient, i.e., multiple comorbidities, polypharmacy, immobility, and depression. Postoperatively, early mobilization is crucial to avoid the deleterious effects of immobility in the older person. Further investigations into the psychosocial issues and cost benefits of limb loss and prosthetic rehabilitation are needed. In addition, comparison of the various rehabilitation protocols and the impact of cardiac resting before rehabilitation are needed.

Late outcome of amputees with premature atherosclerosis

BACKGROUND

Peripheral atherosclerosis in young adults has been associated with a high amputation rate. Our purpose was to examine the natural history of amputees with premature atherosclerosis.

METHODS

We compared 50 consecutive young patients undergoing dysvascular amputation who were 49 years of age or younger (mean age +/- SEM, 43 +/- .7 years) with 75 consecutive men and women ranging in age from 60 to 75 years (mean age, 67 +/- .6 years) who were undergoing major amputations for atherosclerosis during the same period.

RESULTS

Before undergoing amputation 46 (92%) patients in the study group underwent a mean of 3 +/- 0.3 vascular operations, and 49 (65%) older patients in the control group underwent a mean of 2 +/- 0.2 vascular operations (p = 0.003). The mean time from onset of symptoms to first amputation was not different in the study group versus the control group. Of those patients surviving until discharge, 20 (45%) patients in the study group and 21 (31%) patients in the control group became community or household ambulators, whereas 24 (55%) patients in the study group and 47 (69%) patients in the control group were confined to wheelchairs or were bedridden (p = 0.17). Seventeen (74%) patients in the study group who did not require contralateral amputations became community ambulators, as did 18 (38%) members of the control group (p = 0.01). Twenty (40%) patients in the study group and 39 (52%) patients in the control group died during the study period. The mean age at death was 48 +/- 1 years for the study group and 69 +/- .8 years for the control group (p < 0.001). Cumulative 5-year survival (62% patients in study group, 47% patients in control group) was not different between the two groups (p = 0.41, Kaplan-Meier).

CONCLUSIONS

Compared with older counterparts, amputees with premature atherosclerosis have a higher number of failed bypasses before undergoing amputation and die at a younger age. However, both groups have a similar cumulative survival after amputation. Fewer than one half of young patients undergoing dysvascular amputation ultimately achieve ambulation, suggesting that major amputations are a harbinger of long-term disability and dependency in these patients. Because young patients had a higher potential for rehabilitation after unilateral amputation, these patients should be monitored closely for development of ischemia in the contralateral limb.

Late outcomes of limb loss after failed infrainguinal bypass

PURPOSE

Most reports regarding infrainguinal bypass surgical procedures demonstrate benefits well but pay less attention to adverse outcomes and consequences of failure for the patient. For a wider scope of infrainguinal bypass surgical procedures, we evaluated patient-oriented outcomes of limb loss occurring after failed infrainguinal bypass operations.

METHODS

Eighty-one patients with vascular amputations were identified in a retrospective study. Follow-up was complete with a mean of 3.6 years. Life-table and multivariate analyses were used to assess factors influencing the desired outcome goals of rehabilitation. Mortality rates, social function, risk of contralateral amputation, and the ability to walk were used to measure the late outcome.

RESULTS

The long-term survival rate was poor (72% at 1 year; 53% at 3 years) and was not related to traditional risk factors for atherosclerosis. Moreover the risk for contralateral amputation was 10% per year. One year after amputation 81% (47 of 58) of the surviving amputees were walking independently, and 73% (42 of 58) were living at home, 32 with their spouse. At 3 years these results were 73% (27 of 37) and 78% (29 of 37), respectively. In addition, the level of self-care changed significantly (p < 0.001) after amputation. Advanced age (older than 65 years), self-care performance, and living with someone were important predictors of late outcome.

CONCLUSIONS

It is possible for a high percentage of patients with vascular amputations to return home successfully, either walking or in a wheelchair. Moreover this result can be predicted based on preoperative clinical variables. These data may be helpful to guide fitting of prosthetic devices, planning of discharge home, and use of health care resources.

Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot

BACKGROUND

The aim of this study was to determine the current operative risks of the pedal bypass procedure, its durability, and the factors affecting long-term outcome.

METHODS

We prospectively observed 96 patients who consecutively underwent 100 pedal bypasses using autogenous vein grafts for chronic critical ischemia. Of the 100 limbs, 91 had ischemic ulcers or gangrene, and 9 produced rest pain only. Sixty-four patients were diabetic, 21 had renal failure, and 36 had coronary artery disease. Nonreversed saphenous vein grafts were used most frequently (68 translocated, 13 in situ), followed by composite (13) and reversed vein grafts (6). Fifty-two long grafts originated from the iliac or femoral arteries, and 48 short grafts originated from the popliteal or tibial arteries. For the 100 procedures, 102 distal anastomoses were performed--68 to the dorsalis pedis, 8 to the distal posterior tibial, 10 to the common plantar, 2 to the medial plantar, 9 to the lateral plantar, 4 to the lateral tarsal, and 1 to the first dorsal metatarsal arteries--with the aid of an operating microscope.

RESULTS

No patient died during the perioperative period. Two had hemodynamically insignificant myocardial infarctions. Wound complications developed in 12 patients--infection in 7 and hematoma in 5. There were 10 early graft failures, 6 of which could be salvaged, and 96 grafts were patent at dismissal. Mean follow-up was 2.1 years (range 1 month to 6.4 years). Postoperative surveillance identified 33 failed or failing grafts, 16 of which were successfully revised. At 3 years, cumulative primary and secondary patency rates were 60% and 69%, respectively. Factors correlating with increased secondary patency were intraoperative flow rate > or = 50 mL/min (P = 0.004) and diabetes (P < 0.05). Major amputations were performed on 17 limbs. The cumulative foot salvage rate at 3 years was 79%.

CONCLUSION

Pedal bypass is a safe, effective, and durable procedure. It should be considered even for high-risk patients with critical limb ischemia before major amputation is contemplated.

Repeat leg bypass after multiple prior bypass failures

PURPOSE

The optimal treatment of patients with severe lower extremity ischemia after multiple failed prior bypasses is unclear. It is presently unknown whether failure of attempted revascularization in these patients is so likely that such operation should not be elected. We have maintained an aggressive surgical policy of repeated revascularization regardless of prior failures. A review of our clinical experience with this difficult patient group was performed to determine the results of this policy.

METHODS

From 1980 to 1992, 85 revascularization procedures were performed in 81 patients with lower extremity ischemia after failure of two or more prior infrainguinal bypasses in the same leg. All patients were prospectively entered and monitored in our vascular registry. Seventy-two operations were the third procedure, six operations were the fourth procedure, and seven operations were the fifth procedure on the same extremity. Twenty-six of the 85 procedures (30%) were revisions of failing grafts discovered by routine surveillance methods, whereas 59 were replacements of thrombosed grafts. Autogenous reconstruction was used in 67 procedures (79%), and prosthetic reconstruction was used in 18 procedures (21%). The distal anastomosis was to the popliteal artery in 19 patients and infrapopliteal artery in 66.

RESULTS

Mean time to failure of the first leg bypass was 24 months and 4.9 months for the second bypass. Detailed hematologic screening revealed identifiable hypercoagulable disorders in nine (15%) of 59 patients screened after 1987. All nine had anticardiolipin antibodies. The operative mortality rate was 4%. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8%. The limb salvage rate was 69.6% at 4 years.

CONCLUSIONS

These results indicate that limb revascularization after two or more failed leg bypasses results in low operative mortality rates and surprisingly good primary patency and limb salvage rates at 4 years. The patient survival rate through 4 years is unexpectedly high. In our opinion these results justify an aggressive policy of limb vascularization after multiple failed prior bypasses.