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Farber E, Zhu M, McNamara T, Cheng TW, Alonso A, Siracuse JJ. Patients Experience Significant Long-term Social and Health Challenges after Major Lower Extremity Amputation. Ann Vasc Surg 2024:S0890-5096(24)00466-7. [PMID: 39069122 DOI: 10.1016/j.avsg.2024.07.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES Major lower extremity amputation is a significant life-changing event that can have long-term implications. The goal of this study was to assess long-term medical outcomes and social determinants of health (SDH) challenges in this population. METHODS A retrospective review of major lower extremity (above ankle) amputations (2018-2022) was performed at a safety-net tertiary care center. Patients who participated in a SDH survey between 6-months to 1.5 years postoperatively were included for survey analysis. Patient demographics, comorbidities, and perioperative and long-term outcomes were analyzed. RESULTS There were 100 patients included. Mean age was 61.5 years and 23% were of female gender. The majority (57%) were Black race, 20% White race, and 21% Hispanic ethnicity. Comorbidities included diabetes (78%), chronic kidney disease (51%), coronary artery disease (31%), congestive heart failure (23%), previous cerebrovascular events (19%), and 37% used opioids preadmission. At baseline, the majority (62%) lived at home. Guillotine amputation was performed in 24%, with definitive amputation below and above knee in 67% and 33%, respectively. Median length of stay was 7 days. Readmission at 30, 90 days, and 1-year was 13%, 30%, and 43% respectively. The average follow-up was 839 days. At long-term follow-up, 55% lived at home, 25% used opioids, and only 25% were independently ambulatory. In the SDH survey at follow-up, 32% identified at least one SDH challenge, with younger patients more often affected (58 vs. 63 years, P=.031). SDH challenges consisted of food insecurity (17%), housing insecurity (13%), transportation challenges (13%), seeking employment (8%), difficulty paying for utilities (5%) and medications (4%), seeking further education (5%), and difficulty caring for family/friends (4%). On multivariable analysis, having at least one SDH challenge was independently associated with 1-year readmission (OR 6.7, 95% CI 1.3-35.8, P<.001). Older age was associated with lower long-term independent ambulation (OR 0.92, 95% CI 0.85-0.99, P=.025). CONCLUSION After major lower extremity amputation, patients have significant medical and social challenges with fewer living at home, the majority were not independently ambulatory, and one third having at least one SDH challenge. Improvements in long-term support including medical, social, and rehabilitation services are required for this vulnerable population.
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Affiliation(s)
- Elina Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Max Zhu
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas McNamara
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Andrea Alonso
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Chobanian and Avedisian School of Medicine, Boston, MA.
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Al‐Saadi N, Al‐Hashimi K, Popplewell M, Fabre I, Gwilym BL, Hitchman L, Chetter I, Bosanquet DC, Wall ML. The incidence of surgical site infection following major lower limb amputation: A systematic review. Int Wound J 2024; 21:e14946. [PMID: 38961561 PMCID: PMC11222165 DOI: 10.1111/iwj.14946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/05/2024] Open
Abstract
Surgical site infections (SSIs) following major lower limb amputation (MLLA) in vascular patients are a major source of morbidity. The objective of this systematic review was to determine the incidence of SSI following MLLA in vascular patients. This review was prospectively registered with the International Prospective Register of Systematic Reviews (CRD42023460645). Databases were searched without date restriction using a pre-defined search strategy. The search identified 1427 articles. Four RCTs and 21 observational studies, reporting on 50 370 MLLAs, were included. Overall SSI incidence per MLLA incision was 7.2% (3628/50370). The incidence of SSI in patients undergoing through-knee amputation (12.9%) and below-knee amputation (7.5%) was higher than the incidence of SSI in patients undergoing above-knee amputation, (3.9%), p < 0.001. The incidence of SSI in studies focusing on patients with peripheral arterial disease (PAD), diabetes or including patients with both was 8.9%, 6.8% and 7.2%, respectively. SSI is a common complication following MLLA in vascular patients. There is a higher incidence of SSI associated with more distal amputation levels. The reported SSI incidence is similar between patients with underlying PAD and diabetes. Further studies are needed to understand the exact incidence of SSI in vascular patients and the factors which influence this.
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Affiliation(s)
| | | | - Matthew Popplewell
- Black Country Vascular NetworkDudleyUK
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
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Yağız BK, Göktuğ UU, Sapmaz A, Dinç T, Budak AB, Terzioğlu SG. The impact of comorbidities on mortality in patients with non-traumatic major lower extremity amputation. J Wound Care 2023; 32:805-810. [PMID: 38060412 DOI: 10.12968/jowc.2023.32.12.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Major lower limb amputation is generally associated with a high risk of early and late-term mortality. In this study, 30-day, one-year and three-year mortality of non-traumatic major lower extremity amputations and comorbidities affecting the mortality rate were investigated. METHOD Patients who underwent a major lower limb amputation secondary to diabetes or peripheral artery disease between the years 2010-2015 were retrospectively evaluated. Additional to patient demographic data and comorbidities, amputation level, survival and mortality time were extracted. Mortality rates after 30 days, one year and three years were analysed. The associations of the survival to different parameters were evaluated with Kaplan-Meier analysis and log rank test, while the impact of the risk factors on mortality was evaluated with the Cox regression test. RESULTS A total of 193 patients were enrolled in the study. Approximately 60% of patients were aged ≥65 years, and 65.8% were male. Below-knee amputation was performed in 64.8% of patients and above-knee amputation in 35.2% of patients. The mean follow-up of patients was 29.48 months (range: 0-101 months). After non-traumatic major lower extremity amputation, 30-day, one-year and three-year mortality were 16.6%, 38.3% and 60.1%, respectively. On Cox regression analysis, age ≥65 years was the only variable that had significant impact on the 30-day mortality (hazard ratio (HR): 3.4; p=0.012), while age ≥65 years (HR: 2.5, p=0.000), diabetes (HR: 2, p=0.006) and renal failure (HR: 2, p=0.001) were found to have significant impacts on three-year mortality. CONCLUSION The findings of this study showed that >50% of patients with non-traumatic major lower limb amputations died within three years. Advanced age, diabetes and renal failure were the risk factors that increased the mortality. The high mortality rates revealed the importance of employing all hard-to-heal wound treatment options before making an amputation decision. Further, prospective studies are needed to determine the effects of primary disease status and timing of amputation on mortality.
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Affiliation(s)
- Betül Keskinkılıç Yağız
- Ministry of Health Samsun Gazi State Hospital, Department of General Surgery, Samsun, Turkey
| | - Ufuk Utku Göktuğ
- Yeditepe University Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Ali Sapmaz
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Tolga Dinç
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Ali Baran Budak
- Başkent University Faculty of Medicine Alanya Practice and Research Center, Department of Cardiovascular Surgery, Antalya, Turkey
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Martelli E, Enea I, Zamboni M, Federici M, Bracale UM, Sangiorgi G, Martelli AR, Messina T, Settembrini AM. Focus on the Most Common Paucisymptomatic Vasculopathic Population, from Diagnosis to Secondary Prevention of Complications. Diagnostics (Basel) 2023; 13:2356. [PMID: 37510100 PMCID: PMC10377859 DOI: 10.3390/diagnostics13142356] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/02/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Middle-aged adults can start to be affected by some arterial diseases (ADs), such as abdominal aortic or popliteal artery aneurysms, lower extremity arterial disease, internal carotid, or renal artery or subclavian artery stenosis. These vasculopathies are often asymptomatic or paucisymptomatic before manifesting themselves with dramatic complications. Therefore, early detection of ADs is fundamental to reduce the risk of major adverse cardiovascular and limb events. Furthermore, ADs carry a high correlation with silent coronary artery disease (CAD). This study focuses on the most common ADs, in the attempt to summarize some key points which should selectively drive screening. Since the human and economic possibilities to instrumentally screen wide populations is not evident, deep knowledge of semeiotics and careful anamnesis must play a central role in our daily activity as physicians. The presence of some risk factors for atherosclerosis, or an already known history of CAD, can raise the clinical suspicion of ADs after a careful clinical history and a deep physical examination. The clinical suspicion must then be confirmed by a first-level ultrasound investigation and, if so, adequate treatments can be adopted to prevent dreadful complications.
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Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 Viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 Via di Sant'Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 Viale Europa, 32100 Belluno, Italy
| | - Massimo Federici
- Department of Systems Medicine, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Umberto M Bracale
- Division of Vascular Surgery, Federico II Polyclinic, Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, 5 Via S. Pansini, 80131 Naples, Italy
| | - Giuseppe Sangiorgi
- Department of Biomedicine and Prevention, School of Medicine and Surgery, University of Rome Tor Vergata, 1 Viale Montpellier, 00133 Rome, Italy
| | - Allegra R Martelli
- Faculty-Medicine & Surgery, Campus Bio-Medico University of Rome, 21 Via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 Viale del Policlinico, 00161 Rome, Italy
| | - Alberto M Settembrini
- Division of Vascular Surgery, Maggiore Polyclinic Hospital Ca' Granda IRCCS and Foundation, 35 Via Francesco Sforza, 20122 Milan, Italy
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Enea I, Martelli E. Focus on the Prevention of Acute Limb Ischemia: Centrality of the General Practitioner from the Point of View of the Internist. J Clin Med 2023; 12:jcm12113652. [PMID: 37297848 DOI: 10.3390/jcm12113652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/01/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
The thrombotic mechanism, being common to peripheral arterial disease (PAD), acute myocardial infarction (AMI), and stroke, is responsible for the highest number of deaths in the western world. However, while much has been done for the prevention, early diagnosis, therapy of AMI and stroke, the same cannot be said for PAD, which is a negative prognostic indicator for cardiovascular death. Acute limb ischemia (ALI) and chronic limb ischemia (CLI) are the most severe manifestations of PAD. They both are defined by the presence of PAD, rest pain, gangrene, or ulceration and we consider ALI if symptoms last less than 2 weeks and CLI if they last more than 2 weeks. The most frequent causes are certainly atherosclerotic and embolic mechanisms and, to a lesser extent, traumatic or surgical mechanisms. From a pathophysiological point of view, atherosclerotic, thromboembolic, inflammatory mechanisms are implicated. ALI is a medical emergency that puts both limb and the patient's life at risk. In patients over age 80 undergoing surgery, mortality remains high reaching approximately 40% as well as amputation approximately 11%. The purpose of this paper is to summarize the scientific evidence on the possibilities of primary and secondary prevention of ALI and to raise awareness among doctors involved in the management of ALI, in particular by describing the central role of the general practitioner.
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Affiliation(s)
- Iolanda Enea
- Emergency Department, S. Anna and S. Sebastiano Hospital, 81100 Caserta, Italy
| | - Eugenio Martelli
- Division of Vascular Surgery, Department of Cardiovascular Science, S. Anna and S. Sebastiano Hospital, Campania, 81100 Caserta, Italy
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Science, 00131 Rome, Italy
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Tolaymat B, Bye M, Lee D, McMackin KK, Lombardi JV, Batista PM. Postamputation diagnosis of squamous cell carcinoma in a patient with lymphedema. J Vasc Surg Cases Innov Tech 2023; 9:101100. [PMID: 36852314 PMCID: PMC9958079 DOI: 10.1016/j.jvscit.2023.101100] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/13/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023] Open
Abstract
Chronic lymphedema is fraught with morbidity, including tissue loss. We present the case of a woman with long-standing lymphedema suffering from nonhealing ulcerations despite multiple interventions, who underwent below-knee amputation. Surgical pathology yielded a diagnosis of invasive squamous cell carcinoma. We highlight the uncommon association between lymphedema and squamous cell carcinoma, and the importance of routine pathological testing with lower extremity amputations.
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Affiliation(s)
- Besher Tolaymat
- Correspondence: Besher Tolaymat, MD, Divsion of Vascular Surgery, Department of Surgery, Cooper University Hospital, 3 Cooper Plaza, Suite 411, Camden, NJ 08103
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Analysis of 5-year Mortality following Lower Extremity Amputation due to Vascular Disease. Plast Reconstr Surg Glob Open 2023; 11:e4727. [PMID: 36699221 PMCID: PMC9833438 DOI: 10.1097/gox.0000000000004727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/03/2022] [Indexed: 01/13/2023]
Abstract
Mortality rates following major lower extremity amputations (LEAs) 30 days-365 days postoperative have decreased, but 5-year rates remain high at 40.4%-70%. These data may not reflect recent advances in peripheral arterial disease (PAD) care, and comorbidities of chronic PAD may lead to mortality more frequently than the amputation itself. Mortality rates between diabetic and nondiabetic patients were also analyzed. Methods The California Office of Statewide Health Planning and Development hospital database was queried for patients admitted January 1, 2007-December 31, 2018. ICD-9-CM codes identified patients with vascular disease and an amputation procedure. Results There were 26,669 patients. The 30-day, 90-day, 1-year, and 5-year major LEA mortality rates were 4.82%, 8.62%, 12.47%, and 18.11%, respectively. Weighted averages of 30-day, 90-day, 1-year, and 5-year major LEA mortality rates in the literature are 13%, 15.40%, 47.93%, and 60.60%, respectively. Mortality risk associated with vascular disease after amputation (hazard ratio = 22.07) was 11 times greater than risk associated with amputation-specific complications from impaired mobility (hazard ratio = 1.90; P < 0.01). Having diabetes was associated with lower mortality at 30 days, 90 days, and 1 year (P < 0.01) but not at 5 years (P = 0.22). Conclusions This study suggests that people may be living longer after their major LEA than was previously thought. This study suggests that patients' PAD may play a bigger role in contributing to their mortality than complications from loss of mobility postamputation. Although having diabetes was associated with lower postamputation mortality, the difference was no longer significant by 5 years.
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Berli MC, Rancic Z, Schöni M, Götschi T, Schenk P, Kabelitz M, Böni T, Waibel FWA. Salami-Tactics: when is it time for a major cut after multiple minor amputations? Arch Orthop Trauma Surg 2023; 143:645-656. [PMID: 34370043 PMCID: PMC9925494 DOI: 10.1007/s00402-021-04106-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Repetitive minor amputations carry the concomitant risks of multiple surgical procedures, major amputations have physical and economical major drawbacks. The aim of this study was to evaluate whether there is a distinct number of minor amputations predicting a major amputation in the same leg and to determine risk factors for major amputation in multiple minor amputations. MATERIALS AND METHODS A retrospective chart review including 429 patients with 534 index minor amputations between 07/1984 and 06/2019 was conducted. Patient demographics and clinical data including number and level of re-amputations were extracted from medical records and statistically analyzed. RESULTS 290 legs (54.3%) had one or multiple re-amputations after index minor amputation. 89 (16.7%) legs needed major amputation during follow up. Major amputation was performed at a mean of 32.5 (range 0 - 275.2) months after index minor amputation. No particular re-amputation demonstrated statistically significant elevated odds ratio (a.) to be a major amputation compared to the preceding amputation and (b.) to lead to a major amputation at any point during follow up. Stepwise multivariate Cox regression analysis revealed minor re-amputation within 90 days (HR 3.8, 95% CI 2.0-7.3, p <0.001) as the only risk factor for major amputation if at least one re-amputation had to be performed. CONCLUSIONS There is no distinct number of prior minor amputations in one leg that would justify a major amputation on its own. If a re-amputation has to be done, the timepoint needs to be considered as re-amputations within 90 days carry a fourfold risk for major amputation. LEVEL OF EVIDENCE Retrospective comparative study (Level III).
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Affiliation(s)
- Martin C Berli
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Zoran Rancic
- Clinic for Vascular Surgery, University Hospital Zurich, and Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Madlaina Schöni
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Tobias Götschi
- Department of Orthopaedic Surgery, University of Zurich, Institute for Biomechanics, ETH Zurich, Balgrist Campus, Zurich, Switzerland
| | - Pascal Schenk
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Method Kabelitz
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Thomas Böni
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Felix W A Waibel
- Division of "Prosthetics and Orthotics", Department of Orthopedics, Balgrist University Hospital, Forchstrasse 340, 8008, Zürich, Switzerland.
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Hogan WB, Anderson G, Kovoor M, Alsoof D, McDonald CL, Zhang AS, Kuris EO, Johnson JP, Daniels AH. Phantom limb syndrome: Assessment of psychiatric and medical comorbidities associated with Phantom pain in 44,028 below knee amputees. Injury 2022; 53:3697-3701. [PMID: 36163201 DOI: 10.1016/j.injury.2022.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 09/01/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Phantom limb syndrome is a debilitating complication after extremity amputation that poses significant challenges to recovery. This study aims to examine the relationship between phantom limb syndrome and mental and physical comorbidities, including a comparison between phantom limb pain and phantom limb syndrome without pain in below knee amputees. METHODS This is a retrospective cohort study of patients who underwent below knee amputation of the lower extremity in the PearlDiver database, as identified using CPT codes. Analysis was carried out to evaluate the absence or presence of phantom limb syndrome. Matched bivariate analysis accounting for age, sex, Charlson Comorbidity Index score, and region was used to assess whether the presence of pain in phantom limb syndrome patients was associated with increased comorbidity. RESULTS In total, 44,028 patients with below knee amputation were examined: 95% (42,493 patients) did not develop phantom limb syndrome while 4.8% (1,535 patients) of patients did develop phantom limb syndrome. Phantom limb syndrome was significantly associated with increased odds of coexistent major depressive disorder (OR = 1.86, p <0.0001), generalized anxiety disorder (OR = 2.14, p = 0.04), posttraumatic stress disorder (OR = 1.7, p <0.0001), suicidal ideation (OR = 1.62, p <0.0001), obesity (OR = 1.28, p = 0.0007), osteoarthritis (OR = 1.53, p <0.0001), osteoporosis (OR = 1.64, p <0.0001), and low back pain (OR = 2.31, p <0.0001). Analysis of patient cohorts of phantom limb syndrome with pain and those without pain did not reveal a statistically significant relationship between the presence of pain and any dependent variable. CONCLUSIONS This investigation of over 44,000 patients with below knee amputation revealed that patients with phantom limb syndrome exhibit significantly higher rate of psychiatric comorbidities compared to those without documented phantom limb pain. Suicidal ideation, major depressive disorder, generalized anxiety disorder, and post-traumatic stress disorder were especially common, and consequently a multi-disciplinary approach to management is essential.
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Affiliation(s)
- William B Hogan
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - George Anderson
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Matthew Kovoor
- Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Daniel Alsoof
- Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Christopher L McDonald
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Andrew S Zhang
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Eren O Kuris
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Joey P Johnson
- Department of Orthopedics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alan H Daniels
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, RI, United States.
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Korosoglou G, Giusca S, Langhoff R, Lichtenberg M, Lawall H, Schellong S, Stausberg J, Hoffmann U, Enders D, Malyar N. Safety and Effectiveness of Endovascular Therapy for the Treatment of Peripheral Artery Disease in Patients with and without Diabetes Mellitus. Angiology 2022; 73:956-966. [PMID: 35324343 DOI: 10.1177/00033197221075857] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
This study investigated the distribution of risk factors, lesion characteristics and endovascular revascularization (EVR) strategies in patients with peripheral arterial disease (PAD) with vs without diabetes mellitus (DM). Data were collected within the RECcording COurses of vasculaR Diseases (RECCORD) registry. Demographic data, lesion localization (iliac vs femoropopliteal vs below-the-knee (BTK)) and lesion complexity score (LCS) based on number of affected segments, and lesion length (< 10 vs 10-20 vs > 20 cm), EVR strategies and peri-procedural complications were analysed in 786 patients with and 1337 without diabetes mellitus. Patients with diabetes mellitus were older (71.6 ± 9.6 vs 69.4 ± 10.5 years, P < .001) and had higher LCS and more often BTK lesions (P < .05 for all). Lesions were treated less frequently with stents (48.7 vs 59.6%, P < .001) in patients with diabetes mellitus, whereas a non-significant trend was noticed for higher DCB treatment rates (48.3 vs 44.4%, P = .07). Post-interventional ankle-brachial index (ABI) increase was similar (from .77 ± .28 to .92 ± .25 with diabetes mellitus and from .74 ± .21 to .90 ± .20 without diabetes mellitus, P < .001 for both). Peri-/post-procedural complications were low in both groups (4.6%). Patients with diabetes mellitus, who undergo endovascular revascularization are older, have more comorbidities and higher target lesion complexity. However, treatment success rates are similar and complication rates are low.
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Affiliation(s)
| | - Sorin Giusca
- GRN Hospital Weinheim, Cardiology and Vascular Medicine, Weinheim, Germany
| | - Ralf Langhoff
- Department of Angiology, Sankt-Gertrauden-Krankenhaus, Berlin, Germany
| | | | | | | | | | - Ulrich Hoffmann
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, University Hospital Munich, Munich, Germany
| | - Dominic Enders
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Nasser Malyar
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, 39069University Hospital Muenster, Muenster, Germany
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Mufarrih SH, Qureshi NQ, Yunus RA, Katsiampoura A, Quraishi I, Sharkey A, Mahmood F, Matyal R. A Systematic Review and Meta-analysis of General versus Regional Anesthesia for Lower Extremity Amputation. J Vasc Surg 2022; 77:1542-1552.e9. [PMID: 36243265 DOI: 10.1016/j.jvs.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative morbidity in patients undergoing lower extremity amputation (LEA) has remained high. Studies investigating the influence of the anesthetic modality on the postoperative outcomes have yielded conflicting results. The aim of our study was to assess the effects of regional anesthesia vs general anesthesia on postoperative complications for patients undergoing LEA. METHODS We systematically searched PubMed, Embase, MEDLINE, Web of Science, and Google Scholar from 1990 to 2022 for studies investigating the effect of the anesthetic modality on the postoperative outcomes after LEA. Regional anesthesia (RA) included neuraxial anesthesia and peripheral nerve blocks. The outcomes included 30-day mortality, respiratory failure (unplanned postoperative intubation, failure to wean, mechanical ventilation >24 hours), surgical site infection, cardiac complications, urinary tract infection, renal failure, sepsis, venous thrombosis, pneumonia, and myocardial infarction. RESULTS Of the 25 studies identified, we included 10 retrospective observational studies with 81,736 patients, of whom 69,754 (85.3%) had received general anesthesia (GA) and 11,980 (14.7%) had received RA. In the GA group, 50,468 patients were men (63.8%), and in the RA group, 7813 patients were men (62.3%). The results of the meta-analyses revealed that GA was associated with a higher rate of respiratory failure (odds ratio, 1.38; 95% confidence interval, 1.06-1.80; P = .02) and sepsis (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; P < .0001) compared with RA. No differences were found in postoperative 30-day mortality, surgical site infection, cardiac complications, urinary tract infection, renal failure, venous thrombosis, pneumonia, and myocardial infarction between the GA and RA groups. CONCLUSIONS The results of our meta-analysis have shown that GA could be associated with a higher rate of respiratory failure and sepsis compared with RA for LEA.
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Tsai S, Lanier HD, Tran N, Pham T, Huerta S. Current Predictors of Mortality in Veteran Patients Undergoing Major Lower Extremity Amputations: Risk Factors Have Not Changed and Mortality Remains High. Am Surg 2022:31348221074235. [PMID: 35124982 DOI: 10.1177/00031348221074235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Major lower extremity amputation (LEA-above the ankle) carries a high rate of mortality. In the present study, we performed an institutional review of all patients submitting to LEAs at a Veteran Administration Hospital (between 2009 and 2021) accompanied with a review of the literature.For the past 12 years, 1042 LEAs were performed in 603 patients at our hospital. The 30-day, 1-year, and 5-year mortalities were 8.5%, 28.9%, and 53.0%, respectively. Age, hypoalbuminemia, and Clavien-Dindo Class were independent predictors of mortality in all the time intervals in the analysis. Cardiac disease was not an independent predictor of mortality. In 39 studies reviewed, the average 30-day, 1-year, and 5-year mortality was 14%, 36%, and 56%, respectively. There was no difference in mortality in multiple studies analyzed. No significant temporal variation was identified between 1950 and 2000 vs. 2001 and 2021. Predictors of mortality were not substantially different from our institutional experience.The mortality rate for LEAs remains constant over time. Increasing age and hypoalbuminemia are strong predictors of short- and long-term mortality.
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Affiliation(s)
- Shirling Tsai
- Department of Vascular, 20115VA North Texas Health Care System, Dallas, TX, USA
| | - Heather D Lanier
- General Surgery, 12334University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Nguyen Tran
- General Surgery, 12334University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Thai Pham
- General Surgery, 12334University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Sergio Huerta
- General Surgery, 12334University of Texas Southwestern Medical School, Dallas, TX, USA
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13
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Quak S, Pillay N, Wong S, Karthekeyan R, H. Chan D, Y. Liu C. Effects of regional anaesthesia on mortality in patients undergoing lower extremity amputation: A retrospective pooled analysis. Indian J Anaesth 2022; 66:419-430. [PMID: 35903599 PMCID: PMC9316675 DOI: 10.4103/ija.ija_917_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 05/28/2022] [Accepted: 05/28/2022] [Indexed: 11/07/2022] Open
Abstract
Background and Aims: Lower extremity amputation (LEA) is a commonly performed surgery and is associated with significant mortality and morbidity. This review compares the impact of anaesthetic technique on 30-day mortality and other perioperative outcomes in patients undergoing LEA. Methods: A systematic search of databases including PubMed, Embase, Scopus and Cochrane Central Register of Controlled Trials, from January 2010 to March 2021, was performed. Studies were eligible if they compared 30-day mortality following either general anaesthesia (GA) or regional anaesthesia (RA), in adult patients undergoing LEA. Results: Ten retrospective observational studies were identified. Four of these studies utilised a propensity-score matching technique. Based on these four studies, RA when compared to GA, is not associated with a reduction in the 30-day mortality (Odds ratio 0.83, 95% confidence interval (CI): 0.65, 1.05, I2 20%, P = 0.12). Also there is a very low level of evidence that RA may result in a decrease in the hospital length-of-stay and intensive care unit admissions of patients undergoing LEA. Conclusion: RA does not decrease the 30-day postoperative mortality in patients undergoing LEA when compared to GA.
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14
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Buckner J, Cabot J, Fields A, Pounds L, Quint C. Surgical risk calculators in veterans following lower extremity amputation. Am J Surg 2021; 223:1212-1216. [PMID: 34969508 DOI: 10.1016/j.amjsurg.2021.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/24/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the accuracy of multiple risk calculators for 30-day mortality on patients undergoing major lower extremity amputation. METHODS The actual 30-day mortality at a single Veterans Affairs institution was compared to the predicted outcome from the following risk calculators: ACS-NSQIP, VASQIP, amputation scoring tool (AST), and POTTER elective. RESULTS The overall calculated 30-day mortality was similar to the actual mortality with the VASQIP and POTTER elective risk calculators, while the NSQIP and AST over-estimated the 30-day mortality. The predictive accuracy of the POTTER and NSQIP risk calculators were moderate (AUC >0.7), and fair for the VASQIP and AST. CONCLUSION Risk assessment tools can provide adjunctive data on predicted 30-day mortality in patients undergoing major lower extremity amputation. In our study, there were differences in predictability of the risk calculators for lower extremity amputation that should be considered when utilizing a risk assessment tool to improve physician-patient shared decision-making.
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Affiliation(s)
- Jacob Buckner
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA
| | - John Cabot
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA
| | - Alyssa Fields
- Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Lori Pounds
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA; Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA
| | - Clay Quint
- Department of Surgery, Audie Murphy VA Hospital, South Texas Veterans Healthcare System, USA; Department of Vascular and Endovascular Surgery, UT Health San Antonio, San Antonio, TX, 78229, USA.
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15
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Weissler EH, Ford CB, Patel MR, Goodney P, Clark A, Long C, Jones WS. Younger patients with chronic limb threatening ischemia face more frequent amputations. Am Heart J 2021; 242:6-14. [PMID: 34371002 DOI: 10.1016/j.ahj.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Amputations among younger patients with chronic limb threatening ischemia (CLTI) may carry higher personal and societal costs, but younger patients are often not included in CLTI research because of dataset limitations. We aimed to characterize and compare outcomes between younger (<65 years old) and older patients with CLTI. METHODS This retrospective cohort study identified patients with CLTI between July 1, 2014 and December 31, 2017 in the MarketScan commercial claims database, a proprietary set of claims for over 50 million patients with private insurance in the United States. The primary outcome was major adverse limb events (MALE); secondary outcomes included amputations, major adverse cardiovascular events, and statin prescription fills. RESULTS The study cohort included 64,663 people with CLTI, of whom 25,595 (39.6%) were <65 years old. Younger patients were more likely to have diabetes mellitus (54.1% versus 49.9%, P<.001) but less likely to have other comorbidities. A higher proportion of younger patients suffered MALE (31.7% versus 30.2%, P=.002), specifically amputation (11.5% versus 9.3%, P<.001). After adjustment, age <65 years old was associated with a 24% increased risk of amputation (HRadj 1.24, 95%CI 1.18-1.32, P<.001) and a 10% increased risk of MALE (HRadj 1.10, 95%CI 1.07-1.14, P<.001). CONCLUSIONS A significant proportion of commercially insured patients with CLTI are under the age of 65, and younger patients have worse limb-related outcomes. These findings highlight the importance of aggressively treating risk factors for atherosclerosis and intentionally including younger patients with CLTI in future analyses to better understand their disease patterns and outcomes.
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Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Phil Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Amy Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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Ponkilainen VT, Vuorlaakso M, Kaartinen I, Kiiski J, Saarinen E, Huttunen TT, Paloneva J, Mattila VM. The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study. Eur J Vasc Endovasc Surg 2021; 63:138-146. [PMID: 34774371 DOI: 10.1016/j.ejvs.2021.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.
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Affiliation(s)
| | - Miska Vuorlaakso
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Juha Kiiski
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Eva Saarinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland; The Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Juha Paloneva
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland; COXA Hospital for Joint Replacement, Tampere, Finland
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17
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Collins KL, Linassi AG, Zucker-Levin A. A Focus Group- and Patient-Driven Study to Understand Patients' and Health Care Providers' Perspectives on Services for People with Amputation. Physiother Can 2021; 73:244-251. [PMID: 34456441 DOI: 10.3138/ptc-2019-0054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: This study investigates patients' and health care providers' perspectives on the services provided for people with amputation in Saskatoon. Method: We used a qualitative approach, following the Delphi method. A patient-oriented research team designed five questions and presented them to two focus groups. The discussions focused on what worked well in the health care system and what could be improved, what could be improved in the community, future research, and ways to improve specific knowledge translation regarding care of people with amputation to therapists. Results: The two focus groups consisted of 48 panellists, all community members and health care professionals. The themes that emerged included positive experiences with prosthetic care and the individual people responsible for amputee care and improvements needed to streamline the pathways of care, community support, education, and research into all aspects of amputation. Conclusions: Amputation is not just a one-time medical procedure; people with amputation need lifelong support from health care providers and the community. Clear pathways of care, access to immediate support, amputee-specific education for health care providers, better patient education, increased physical therapy, and enhanced resources and care were identified as areas in need of improvement. This study will, we hope, form the basis of future research to continually improve the quality of care and support for people living with amputation.
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Affiliation(s)
- Kassondra L Collins
- Health Sciences, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Gary Linassi
- Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Sciences, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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18
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Andersen JC, Mannoia KA, Patel ST, Leong BV, Murga AG, Teruya TH, Kiang SC, Abou-Zamzam AM. Factors Affecting One-Year Outcomes After Major Lower Extremity Amputation in the Vascular Quality Initiative Amputation Registry. Am Surg 2021; 87:1569-1574. [PMID: 34130510 DOI: 10.1177/00031348211024639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Major lower extremity amputation (LEA) results in significant morbidity and mortality. This study identifies factors contributing to adverse long-term outcomes after major LEA. STUDY DESIGN Amputations in the Vascular Quality Initiative (VQI) long-term follow-up database from 2012 to 2017 were included. Multivariable logistic regression determined which significant patient factors were associated with 1-year mortality, long-term functional status, and progression to higher level amputation within 1 year. RESULTS 3440 major LEAs were performed and a mortality rate of 19.9% was seen at 1 year. Logistic regression demonstrated that 1-year mortality was associated with post-op myocardial infarction (MI) (odds ratio (OR) 1.7, CI 1.02-2.97, P = .04), congestive heart failure (CHF) (OR 1.9, confidence interval (CI) 1.56-2.38, P < .001), hypertension (HTN) (OR 1.31, CI 1.00-1.72, P = .05), chronic obstructive pulmonary disease (COPD) (OR 1.36, CI 1.13-1.63, P < .001), and dependent functional status (OR 2.01, CI 1.67-2.41, P < .001). A decline in ambulatory status was associated with COPD (OR 1.36, CI 1.09-1.68, P = .006). Dependent functional status was protective against revision to higher level amputation (OR .18, CI .07-.45, P < .001). CONCLUSION In the VQI, 1-year mortality after major LEA is nearly 20% and associated with HTN, CHF, COPD, dependent functional status, and post-op MI. Decreased functional status at 1 year was associated with COPD, and progression to higher level amputation was less likely in patients with dependent functional status.
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Affiliation(s)
- James C Andersen
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Kristyn A Mannoia
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sheela T Patel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Beatriz V Leong
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Allen G Murga
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Theodore H Teruya
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Sharon C Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Ahmed M Abou-Zamzam
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA, USA
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19
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A predictive score for 30-day survival for patients undergoing major lower limb amputation for peripheral arterial obstructive disease. Updates Surg 2021; 73:1989-2000. [PMID: 34120323 PMCID: PMC8500910 DOI: 10.1007/s13304-021-01085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/07/2021] [Indexed: 11/25/2022]
Abstract
To analyze outcomes following major lower extremity amputations (mLEAs) for peripheral arterial obstructive disease, gangrene, infected non-healing wound and to create a risk prediction scoring system for 30-day mortality. In this single-center, retrospective, observational cohort study. All patients treated with above-the-knee amputation (AKA) or below-the-knee amputation (BKA) between January 1st, 2010 and June 30th, 2018 were identified. The primary outcome of interest was early (≤ 30 days) mortality. Secondary outcomes were postoperative complications and freedom from amputation stump revision/failure. We identified 310 (77.7%) mLEAs performed on 286 patients. There were 188 (65.7%) men and 98 (34.3%) women with a median age of 79 years (IQR, 69–83 years). We performed 257 (82.9%) AKA and 53 (17.1%) BKA. There were 49 (15.8%) early deaths, which did not differ among the age quartiles of this cohort (15.4% vs. 14.3% vs. 15.4% vs. 19.5%, P = 0.826). Binary logistic regression analysis identified age > 80 years (OR 2.24, 95% CI 1.17–4.31; P = 0.015), chronic obstructive pulmonary disease (OR 2.12, 95% CI 1.11–4.06; P = 0.023), and hemodialysis (OR 2.52, 95% CI 1.15–5.52; P = 0.021) to be associated with early mortality. The final score (range 0–10) identified two subgroups with different mortality at 30 days: lower-risk (score < 4, 10.8%), and higher-risk (score ≥ 4: 28.7%; OR 3.2, 95% CI 1.63–6.32; P < 0.001). In our experience, mLEAs still have a 14% mortality rate over the years. Our lower-risk group (score < 4) is characterized by a lower rate of perioperative death and longer survival.
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20
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Vuorlaakso MA, Uimonen MM, Kuitunen IM, Ponkilainen VT, Mattila VM. During the COVID-19 pandemic in Finland, the number of minor lower limb amputations decreased, whereas major amputations increased. Br J Surg 2021; 108:e292-e293. [PMID: 34118149 DOI: 10.1093/bjs/znab186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/03/2021] [Indexed: 11/13/2022]
Abstract
During the COVID-19 lockdown in Finland, the number of minor amputations decreased whereas transtibial amputations increased. This was an indication of delayed access to treatment leading to higher amputation. Transfemoral amputations decreased during 2020, which may be linked to higher mortality.
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Affiliation(s)
- M A Vuorlaakso
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland.,Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - M M Uimonen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - I M Kuitunen
- School of Medicine, University of Eastern Finland, Kuopio, Finland.,Emergency Department, Mikkeli Central Hospital, Mikkeli, Finland
| | - V T Ponkilainen
- Department of Surgery, Central Finland Hospital Nova, Jyväskylä, Finland
| | - V M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland.,Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland.,COXA Hospital for Joint Replacement, Tampere, Finland
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21
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Shutze W, Gable D, Ogola G, Yasin T, Madhukar N, Kamma B, Alniemi Y, Eidt J. Sex, age, and other barriers for prosthetic referral following amputation and the impact on survival. J Vasc Surg 2021; 74:1659-1667. [PMID: 34082007 DOI: 10.1016/j.jvs.2021.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 05/01/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite advances in peripheral vascular disease treatment, lower extremity amputation continues to be necessary in a significant number of patients. Up to 80% of amputees are not referred for prosthetic fitting. The factors contributing to referral decisions have not been adequately investigated, nor has the impact of prosthetic referral on survival. We characterized differences between patients who were successfully referred to our in-house prosthetists and those who were not, and identified factors associated with prosthetic referral and predictive of survival. METHODS This was a retrospective analysis of all patients who underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to June 30, 2017. Data regarding age, sex, race, body mass index (BMI), diabetes, hypertension, hyperlipidemia, end-stage renal disease, prior coronary artery bypass graft surgery, congestive heart failure, tobacco use, American Society of Anesthesiologists (ASA) score, previous arterial procedure, chronic obstructive pulmonary disease, statin use, postoperative ambulatory status, level of amputation, stump revision, and referral for prosthesis were collected. Survival was determined from a combination of sources, including the Social Security Death Master Index, multiple genealogic registries, and internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis referral. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality. RESULTS There were 293 patients included in this study. Mean age was 66 years, and mean BMI 27 kg/m2. The majority of patients were male (69%), white (53%), with diabetes (65.4%) and hypertension (77.5%), and underwent below-the-knee amputation (BKA) (73%). Prosthetic referral occurred in 123 (42.0%). Overall 5-year survival was 61.7% (95% confidence interval [CI], 55.9%-68.1%) (BKA 64.7% [95% CI, 57.9%-72.3%]; above-the-knee amputation 53.8% [95% CI, 43.4%-66.6%]). On multivariate analysis, age >70 years, female sex, diabetes, ASA score 4 or 5, and current tobacco use were associated with no referral for prosthetic fitting. Patients with BMI 25 to 30, a previous arterial procedure, BKA, and history of stump revision were more likely to be referred. Factors associated with decreased survival were increasing age, higher ASA class, black race, and BMI; prosthetic referral was seen to be protective. CONCLUSIONS We identified multiple patient factors associated with prosthetic referral, as well as several characteristics predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. Further research is needed to determine whether the factors identified as associated with nonreferral are markers for patient characteristics that make them clinically unsuitable for prosthetic fitting or if they are symptoms of unconscious bias or of the patient's access to care.
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Affiliation(s)
- William Shutze
- Heart Hospital Baylor Plano, Plano, Tex; Texas Vascular Associates, Plano, Tex.
| | - Dennis Gable
- Heart Hospital Baylor Plano, Plano, Tex; Texas Vascular Associates, Plano, Tex
| | - Gerald Ogola
- Baylor Scott and White Research Institute, Dallas, Tex
| | | | | | | | | | - John Eidt
- Texas Vascular Associates, Plano, Tex; Baylor University Medical Center, Dallas, Tex
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22
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Nypaver TJ. Chronic Limb-Threatening Ischemia: Revascularization Versus Primary Amputation. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00294-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation 2021; 143:e875-e891. [PMID: 33761757 DOI: 10.1161/cir.0000000000000967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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ERŞEN Ö, KILINÇ NS, BİLEKLİ AB, NEYİŞCİ Ç, BEK D. Türkiye’de ampütasyonların endikasyonları, komplikasyonları ve revizyonları. EGE TIP DERGISI 2020. [DOI: 10.19161/etd.833737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tsvetkov VO, Gorshunova EM, Kolovanova OV, Kozlov JA, Gobegishvili VV. Two-phase amputation among critically ill patients with ischemic gangrene of lower limbs as a way to improve treatment outcome. Cohort study. Ann Med Surg (Lond) 2020; 60:587-591. [PMID: 33304569 PMCID: PMC7708686 DOI: 10.1016/j.amsu.2020.11.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/13/2020] [Accepted: 11/14/2020] [Indexed: 11/16/2022] Open
Abstract
Background The results of lower limb amputation, especially in critically ill patients with severe endogenous intoxication, sepsis, multi-organ failure and severe concomitant diseases are still unsatisfactory. Guillotine amputation is a method routinely used to reduce wound complications associated with wet gangrene and severe cases of diabetic foot, however, it is unclear how well it could help to decrease mortality and improve functional outcome when dealing with critically ill patients. The objective of the study was to estimate the effectiveness of two-phase method of urgent low limb amputation among critically ill patients with high risk of complications. The effectiveness was evaluated in terms of perioperative mortality, frequency of early complications and ultimate level of limb loss. Materials and methods Two cohort groups of patients with acute lower limb gangrene were retrospectively matched. Approximately 25.8% of patients from the comparison (control) group (N = 240) died without surgery due to severity of their condition and ineffective pre-operative treatment. The remaining patients underwent one-phase high-level amputation after 48–72 h of pre-operative intensive care. The experimental group consisted of 153 patients who underwent guillotine amputation at the lower part of tibia (34.6%), knee disarticulation (32.0%), or open thigh amputation (33.3%), depending on the level of irreversible soft tissue necrosis. The reamputation with the stump shaping was performed later when their health status improved. Results The assessment of treatment outcomes showed that the two-phase amputation in critically ill patients (i) decreased the mortality from 48.7 to 37.9%, (ii) reduced the risk of wound complications from 20.9 to 11.1%, and (iii) improved functional results by saving the knee joint in 34.6 versus 4.5% in comparison/control group. Conclusion The method of two-phase amputation is recommended for critically ill patients. Urgent guillotine amputation allows reducing lethality in critically ill patients with gangrene. Reamputation as planned second stage of surgery allows to decrease a risk of wound complications. Two-stages approach allows to perform more distant amputation in some cases.
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Affiliation(s)
- Vitaly O Tsvetkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia
| | - Elena M Gorshunova
- V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia
| | - Olga V Kolovanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia
| | - Jury A Kozlov
- V.V. Vinogradov Moscow Municipal Hospital, Moscow Healthcare Department, Moscow, Russia
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Hall MR, Kalbaugh CA, Tsujimoto TH, McGinigle KL. Regional Anaesthesia Alone is Reasonable for Major Lower Extremity Amputation in High Risk Patients and May Initiate a More Efficacious Enhanced Recovery Programme. Eur J Vasc Endovasc Surg 2020; 60:747-751. [DOI: 10.1016/j.ejvs.2020.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/19/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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Andersen JC, Gabel JA, Mannoia KA, Kiang SC, Patel ST, Teruya TH, Bianchi C, Abou-Zamzam AM. 5-Item Modified Frailty Index Predicts Outcomes After Below-Knee Amputation in the Vascular Quality Initiative Amputation Registry. Am Surg 2020; 86:1225-1229. [DOI: 10.1177/0003134820964190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Patient frailty indices are increasingly being utilized to anticipate post-operative complications. This study explores whether a 5-factor modified frailty index (mFI-5) is associated with outcomes following below-knee amputation (BKA). All BKAs in the vascular quality initiative (VQI) amputation registry from 2012-2017 were reviewed. Preoperative frailty status was determined with the mFI-5 which assigns one point each for history of diabetes, chronic obstructive pulmonary disease or active pneumonia, congestive heart failure, hypertension, and nonindependent functional status. Outcomes included 30-day mortality, unplanned return to odds ratio (OR), post-op myocardial infarction (MI), post-op SSI, all-cause complication, revision to higher level amputation, disposition status, and prosthetic use. 2040 BKAs were performed. Logistic regression showed an increasing mFI-5 score that was associated with higher risk of combined complications (OR 1.22, confidence interval [CI] 1.07-1.38, P < .05), 30-day mortality (OR 1.60, CI 1.19-2.16, P < .05), post-op MI (OR 1.79, CI 1.30-2.45, P < .05), and failure of long-term prosthetic use (OR 1.17, CI 1.03-1.32, P < .05). In the VQI, every one-point increase in mFI-5 is associated with an increased risk of 22% for combined complications, 60% for 30-day mortality, nearly 80% for post-op MI, and 17% for failure of prosthetic use in BKA patients. The mFI-5 frailty index should be incorporated into preoperative planning and risk stratification.
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Affiliation(s)
- James C. Andersen
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Joshua A. Gabel
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Kristyn A. Mannoia
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Sharon C. Kiang
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Sheela T. Patel
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Theodore H. Teruya
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | - Christian Bianchi
- Division of Vascular Surgery, Loma Linda University Health, Loma Linda, CA, USA
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Long CA, Mulder H, Fowkes FGR, Baumgartner I, Berger JS, Katona BG, Mahaffey KW, Norgren L, Blomster JI, Rockhold FW, Hiatt WR, Patel MR, Jones WS, Nehler MR. Incidence and Factors Associated With Major Amputation in Patients With Peripheral Artery Disease. Circ Cardiovasc Qual Outcomes 2020; 13:e006399. [DOI: 10.1161/circoutcomes.119.006399] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Peripheral artery disease (PAD) is associated with increased risk of mortality, cardiovascular morbidity, and major amputation. Data on major amputation from a large randomized trial that included a substantial cohort of patients without critical limb ischemia (CLI) have not been described. The objective was to describe the incidence and types of amputations in the EUCLID trial (Examining Use of Ticagrelor in Peripheral Artery Disease) population, subcategorize amputations in the CLI versus no CLI cohorts, and describe the events surrounding major amputation.
Methods and Results:
Postrandomization major amputation was analyzed in the EUCLID trial. Patients were stratified by baseline CLI status. The occurrence of major amputation was ascertained and defined as the highest level. Perioperative events surrounding major amputation were obtained including acute limb ischemia, revascularization, and all-cause mortality. All variables were assessed for significance in univariable and multivariable models. The rate of major amputation during the course of the trial was 1.6% overall, 8.4% in the CLI at baseline group, and 1.2% in the no CLI at baseline group. The annualized rate of major amputation was 0.6% in PAD overall, 3.9% in the CLI at baseline group, and 0.5% in the no CLI at baseline group. Several factors were associated with increased risk of major amputation, including history of amputation, the presence of diabetes mellitus, baseline Rutherford category 4 to 6, and an ankle-brachial index <0.8. Factors associated with a lower risk for major amputation included prior statin use. The 30-day mortality rate after major amputation was 6.5% overall, 5.6% in the CLI at baseline group, and 6.8% in the no CLI at baseline group. The annual mortality rate following major amputation was 22.8% in the CLI at baseline group and 16.0% in the no CLI at baseline group.
Conclusions:
The risk factors for major amputation in EUCLID patients are similar to previous large registries’ reports except for diabetes mellitus in patients with CLI. The mortality following major amputation is lower in the EUCLID trial compared with registry data.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01732822.
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Affiliation(s)
- Chandler A. Long
- Department of Surgery, Division of Vascular Surgery and Endovascular Surgery (C.A.L.), Duke University Health System, Durham, NC
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
| | - F. Gerry R. Fowkes
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, United Kingdom (F.G.R.F.)
| | - Iris Baumgartner
- Division of Angiology, Swiss Cardiovascular Centre, Inselspital, Bern University Hospital, University of Bern, Switzerland (I.B.)
| | - Jeffrey S. Berger
- Departments of Medicine (J.S.B.), New York University School of Medicine
- Surgery (J.S.B.), New York University School of Medicine
| | | | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, CA (K.W.M.)
| | - Lars Norgren
- Faculty of Medicine and Health, Örebro University, Sweden (L.N.)
| | - Juuso I. Blomster
- Heart Centre, Turku University Hospital, University of Turku, Finland (J.I.B.)
| | - Frank W. Rockhold
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
| | - William R. Hiatt
- Department of Medicine, Division of Cardiology (W.R.H.), University of Colorado School of Medicine and CPC Clinical Research, Aurora
| | - Manesh R. Patel
- Department of Medicine, Division of Cardiology (M.R.P., W.S.J.), Duke University Health System, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
- Department of Surgery, Division of Vascular Surgery and Endovascular Surgery (M.R.N.), University of Colorado School of Medicine and CPC Clinical Research, Aurora
| | - W. Schuyler Jones
- Department of Medicine, Division of Cardiology (M.R.P., W.S.J.), Duke University Health System, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (H.M., F.W.R., M.R.P., W.S.J.)
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D'cruz RT, Chong TT, Tan TF, Ting ZYP, Lee QWS, Wong TH, Yap HY, Tang TY. The Modified Frailty Index Does Not Predict Mortality After Major Lower Extremity Amputation for Peripheral Arterial Disease in an Asian Population. Ann Vasc Surg 2020; 69:298-306. [PMID: 32505677 DOI: 10.1016/j.avsg.2020.05.063] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 05/17/2020] [Accepted: 05/21/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with critical limb ischemia (CLI) who undergo major lower extremity amputation (LEA) have been associated with high one-year mortality rates. Previous western-based studies have identified risk factors that exponentiate these poor outcomes, including nonambulatory status and cardiovascular morbidity. We assessed the effect of frailty, using the modified frailty index (mFI) in a cohort undergoing major LEA for CLI to predict mortality, perioperative complications, and unplanned readmissions in a tertiary institution from Singapore. METHODS Data on patients who had undergone major LEA from January 2016 to December 2017 were collected retrospectively. Inclusion criteria were below-knee amputations (BKAs) or above-knee amputations (AKAs) performed for peripheral arterial disease-related tissue loss or sepsis only. Patients were categorized into 3 risk groups based on the 11-variable mFI: low mFI, 0-0.27; moderate mFI, 0.36-0.54; and high mFI ≥0.63. Univariate and multivariate analysis was performed using logistic regression analysis. RESULTS 211 patients underwent major LEA, of whom 133 (63.0%) had undergone BKA. The mean mFI was 0.41 (range 0-0.81). 84/211 (39.8%) died within 1 year after the procedure, with mortality rates of 25/65 (38.4%), 49/127 (38.6%), and 10/19 (52.6%) in the low-, moderate-, high-mFI categories, respectively. High and moderate mFI had failed to demonstrate an increased risk of mortality when compared with the low-mFI group (P > 0.05). 91/211 (43.1%) patients had perioperative complications, whereas 27/211 (12.8%) patients were readmitted within 30 days of discharge. Myocardial infarction, chronic kidney disease, and atrial fibrillation were found to be predictive of poor outcomes after major LEA. CONCLUSIONS Frailty as measured with the mFI did not predict outcome after major LEA. This could be due to confounding effects such as high prevalence of renal dysfunction and the constancy of diabetes and peripheral vascular disease in this population that would reduce the differentiation of patients using the mFI.
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Affiliation(s)
| | - Tze Tec Chong
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Ting Fang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Singapore
| | - Hao Yun Yap
- Department of Vascular Surgery, Singapore General Hospital, Singapore
| | - Tjun Yip Tang
- Department of Vascular Surgery, Singapore General Hospital, Singapore.
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A prothrombotic state and denser clot formation in patients following acute limb ischemia of unknown cause. Thromb Res 2020; 187:32-38. [PMID: 31951936 DOI: 10.1016/j.thromres.2020.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/09/2019] [Accepted: 01/08/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Fibrin clot structure differs between healthy individuals and those following thromboembolic events. Dense and poorly lysable fibrin clots have also been reported in peripheral artery disease. We studied fibrin clot properties and its determinants in individuals with a history of acute lower limb ischemia (ALI) of unknown cause. MATERIALS AND METHODS In this case-control study, we enrolled 43 patients who experienced ALI of unknown cause, and two age-and sex-matched reference groups: (1) patients with cryptogenic non-lacunar stroke (n = 43) and (2) individuals without any history of thromboembolism (n = 43, control group). Plasma fibrin clot properties, along with thrombin generation and fibrinolysis markers were assessed following ≥3 months of anticoagulation. RESULTS Compared with the control group, the ALI group exhibited more compact plasma fibrin clots (13.4% lower permeability [Ks], p = .001), decreased formed clot lysis (12.5% lower D-Drate, p = .001) and unaltered clot lysis potential, along with enhanced thrombin generation potential (49% higher peak thrombin concentration, p < .0001). There were no differences in these variables between ALI and stroke patients. Patients with ALI had slightly higher α2-antiplasmin and lower plasminogen activator inhibitor 1 levels compared with the stroke and control groups (all p < .01). CONCLUSIONS Patients who experienced ALI of unknown cause display a prothrombotic fibrin clot phenotype, including increased clot density and hypofibrinolysis associated with higher thrombin generation, which might suggest potential benefits from prolonged anticoagulation in this disease.
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Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Risk prediction of 30-day mortality after lower extremity major amputation. J Vasc Surg 2019; 70:1868-1876. [DOI: 10.1016/j.jvs.2019.03.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
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Aljarrah Q, Allouh MZ, Bakkar S, Aleshawi A, Obeidat H, Hijazi E, Al-Zoubi N, Alalem H, Mazahreh T. Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community. BMC Surg 2019; 19:170. [PMID: 31722699 PMCID: PMC6852935 DOI: 10.1186/s12893-019-0637-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Background We aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan. Methods Clinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated. Results The study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA. Conclusions In developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.
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Affiliation(s)
- Qusai Aljarrah
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.,Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, 17666, UAE
| | - Sohail Bakkar
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Abdelwahab Aleshawi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Hasan Obeidat
- School of Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Emad Hijazi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Nabil Al-Zoubi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Heba Alalem
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Tagleb Mazahreh
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
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Lee MS, Choi BG, Rha SW. Impact of diabetes mellitus on 5-year clinical outcomes following successful endovascular revascularization for peripheral artery disease. Vasc Med 2019; 25:33-40. [DOI: 10.1177/1358863x19879751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Endovascular therapy is a viable treatment option for symptomatic peripheral artery disease (PAD). Diabetes mellitus is a major risk factor for PAD. We evaluated the long-term impact of diabetes mellitus in patients with PAD who underwent endovascular therapy. In this prospective registry of 765 patients who underwent endovascular therapy for symptomatic PAD, 560 had diabetes and 205 did not have diabetes. Propensity score matching (PSM) analysis was performed to adjust for any potential confounders. The primary endpoints were 5-year major adverse cardiac and cerebrovascular events (MACE) and major adverse limb events (MALE). After PSM analysis, baseline clinical and limb characteristics were similar in patients with diabetes and in patients without diabetes. Patients with diabetes had a higher rate of major hematoma (> 4 cm) (9.9% vs 3.3%, p = 0.038). At 5-year clinical follow-up, patients with diabetes and patients without diabetes had similar rates of MACE (20.7% vs 20.7%, log rank p = 0.989) and MALE (19.8% vs 24.5%, log rank p = 0.312), as well as the individual endpoints. In subgroup analysis adjusted by PSM, female patients with diabetes had a higher risk of MALE (hazard ratio 0.31, 95% CI 0.13–0.69, p = 0.004). Although there was a higher rate of major hematoma, patients with diabetes who underwent endovascular therapy had similar 5-year cardiac and vascular outcomes compared with patients without diabetes. Bleeding avoidance strategies, including optimal antiplatelet and antithrombotic therapy, and meticulous vascular access techniques, are needed in patients with diabetes to reduce the risk of bleeding and its deleterious impact on morbidity and mortality.
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Affiliation(s)
- Michael S Lee
- Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Byoung Geol Choi
- Department of Medicine, Korea University Graduate School, Seoul, Korea
| | - Seung-Woon Rha
- Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
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Theriot J, Bhattarai P, Finlay DJ. A Reevaluation of the Gritti-Stokes (Above-Knee) Amputation for the Nonambulatory Patient. Ann Vasc Surg 2019; 60:468-473. [DOI: 10.1016/j.avsg.2019.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 02/04/2019] [Accepted: 03/15/2019] [Indexed: 11/16/2022]
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Andersen J, Gabel J, Mannoia K, Kiang S, Patel S, Teruya T, Bianchi C, Abou-Zamzam A. Association between Preoperative Indications and Outcomes after Major Lower Extremity Amputation. Am Surg 2019. [DOI: 10.1177/000313481908501002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite aggressive limb salvage techniques, lower extremity amputation (LEA) is frequently performed. Major indications for LEA include ischemia and uncontrolled infection (UI). A review of the national Vascular Quality Initiative amputation registry was performed to analyze the influence of indication on outcomes after LEA. Retrospective review of the Vascular Quality Initiative LEA registry (2012–2017) identified all above- and below-knee amputations. Outcome measures included 30-day mortality, return to operating room (OR), postoperative myocardial infarctions, and postoperative SSI. Indications for surgery included ischemic rest pain, ischemic tissue loss (TL), acute limb ischemia (ALI), UI, and neuropathic TL. A total of 6701 patients met the inclusion criteria. The indications for surgery included TL (49.0%), UI (31.7%), ALI (8.0%), rest pain (6.6%), and neuropathic TL (2.3%). Patients with ALI had the highest 30-day mortality (12.0%) compared with TL (6.6%) and UI (6.4%) [ P < 0.001]. The highest rate of return to OR occurred in the UI group (12.6%) [ P < 0.001]. Multivariate analysis demonstrated that patients with UI have significantly higher rates of return to OR, whereas those with ALI have a 30-day mortality twice as high as other indications (both P < 0.001). These data can inform expectations after LEA based on the indications for surgery.
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Affiliation(s)
| | - James Andersen
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Joshua Gabel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Kristyn Mannoia
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Sharon Kiang
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Sheela Patel
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Theodoreh Teruya
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Christian Bianchi
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Ahmedm Abou-Zamzam
- Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, California
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Stalling P, Engelbertz C, Lüders F, Meyborg M, Gebauer K, Waltenberger J, Reinecke H, Freisinger E. Unmet medical needs in intermittent Claudication with diabetes and coronary artery disease-A "real-world" analysis on 21 197 PAD patients. Clin Cardiol 2019; 42:629-636. [PMID: 31017298 PMCID: PMC6553564 DOI: 10.1002/clc.23186] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Peripheral artery disease (PAD) is frequently co-prevalent with coronary artery disease (CAD) and diabetes (DM). The study aims to define the burden of CAD and/ or DM in PAD patients at moderate stages and further to evaluate its impact on therapy and outcome. METHODS Study is based on health insurance claims data of the BARMER reflecting an unselected "real-world" scenario. Retrospective analyses were based on 21 197 patients hospitalized for PAD Rutherford 1-3 between 1 January 2009 to 31 December 2011, including a 4-year follow-up (median 775 days). RESULTS In PAD patients, CAD is prevalent in 25.3% (n = 5355), DM in 23.5% (n = 4976), and both CAD and DM in 8.2% (n = 1741). Overall, in-hospital mortality was 0.4%, being increased if CAD was present (CAD alone: OR 1.849; 95%-CI 1.066-3.208; DM alone: OR 1.028; 95%-CI 0.520-2.033; CAD and DM: OR 3.115; 95%-CI 1.720-5.641). Both, CAD and DM increased long-term mortality (CAD alone: HR 1.234; 95%-CI 1.106-1.376; DM alone: HR 1.260; 95%-CI 1.125-1.412; CAD and DM: HR 1.76; 95%-CI 1.552-1.995). DM further increased long-term amputation risk (DM alone: HR 2.238; 95%-CI 1.849-2.710; DM and CAD: HR 2.199; 95%-CI 1.732-2.792), whereas CAD (alone) did not. CONCLUSIONS In a greater perspective, the data identify also mild to modest stage PAD patients at particular risk for adverse outcomes in presence of CAD and/or DM. CAD and DM both are related with a highly increased risk of long-term mortality even in intermittent claudication, and DM independently increased amputation risk.
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Affiliation(s)
- Philipp Stalling
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Christiane Engelbertz
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | | | - Matthias Meyborg
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Katrin Gebauer
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Johannes Waltenberger
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany
| | - Holger Reinecke
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Muenster, Germany.,Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
| | - Eva Freisinger
- Division of Vascular Medicine, Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure Medicine, University Hospital Muenster, Muenster, Germany
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