Vascular disease in the elderly patient

The cost of major lower limb amputation: a 12-year experience

BACKGROUND

The amputee population is elderly, has significant medical co-morbidities and perioperative mortality leading to high financial implications. Commonly used outcomes in the literature are survival, prosthetic use and mobility.

OBJECTIVES

Our study aims to share our 12-year experience of amputee care, concentrating on perioperative mortality and patient rehabilitation.

STUDY DESIGN

Observational study in the form of a retrospective case series.

METHODS

In total, 130 amputations, performed between January 1998 and December 2009, were followed up for a mean of three and a half years and analyzed for demographics, vascular history, operation details, prosthetic use, mobility and mortality.

RESULTS

The population was 59.2% male, had a mean age of 73 and the most common indication for amputation was critical ischaemia (78.5%). The average length of acute inpatient stay was 63 days with a 30-day mortality rate of 15.3% and inpatient mortality of 29.3%. In total, 63.3% of patients were issued with a prosthesis with 48.2% of all patients achieving at least indoor mobility, transtibial (49.9%) rehabilitated better than transfemoral amputees (24.3%).

CONCLUSIONS

Our data support the urgent need for action to improve perioperative mortality in the amputee population, with the added advantage of reducing its financial impact. Clinical relevance Our study gives an overview of the clinical journey taken by a 12-year amputee population. By following this cohort from initial procedure through to rehabilitation or mortality we provide the reader with a valuable insight into the difficulties of managing this population and the likely outcomes for these patients.

Initial experience with dorsal venous arch arterialization for limb salvage

Surgical reconstruction for patients with symptomatic lower extremity arterial occlusive disease is successful when a suitable distal target vessel is present. In patients with unreconstructable disease, practical surgical options are at a minimum. We report our initial experience with dorsal venous arch arterialization (DVAA) for limb salvage. Patients with a lower extremity arteriogram and tibia/plantar artery duplex scan demonstrating unreconstructable occlusive disease were evaluated for DVAA. The venous arch valve lysis technique consisted of retrograde balloon catheter, arterial dilator disruption, and direct valvulectomy. Outcome variables included patency, limb salvage rate, and toe pressure alterations. Initial results suggest that DVAA may be a viable option for end-stage limb salvage. Application of the DVAA appears to be more suitable for patients with symptoms secondary to atherosclerosis than those with Buerger's disease.

Factors affecting the results of surgery for chronic critical leg ischemia--a nationwide survey. Finnvasc Study Group

PURPOSE

To assess the factors affecting immediate outcome of surgery for chronic critical leg ischemia, especially the influence of surgeon's caseload and hospital volume.

METHODS

The data of Finnvasc registry were retrospectively analyzed. A total of 11,747 surgical vascular reconstructions included 1,761 operations for chronic critical leg ischemia during 1991 to 1994.

RESULTS

The 30-day postoperative leg amputation rate was 7.5% and the mortality rate 4.7%. Diabetes, previous vascular surgery or amputation, preoperative ulcer or gangrene, a surgeon's annual caseload fewer than 10 operations, and hospital volume fewer than 20 operations for chronic critical leg ischemia adversely affected amputation rates. The presence of coronary artery disease and renal dysfunction increased postoperative mortality rates. Both amputation rates and postoperative mortality rates were affected by the type of procedure.

CONCLUSIONS

A surgeon's caseload and hospital volume affect amputation rate, but not mortality rate, in patients operated for chronic critical leg ischemia.

Vascular ultrasonography

Although vascular ultrasonography has been established as an essential diagnostic tool in many clinical settings, its role in the emergency department patient population is uncertain. Preliminary reports of emergency physician--directed ultrasonography are promising. Further studies are needed to establish its reliability and suitability in the emergency department setting.

Surgical treatment for chronic critical leg ischaemia: a 5 year follow-up of socioeconomic outcome

OBJECTIVES

To evaluate the costs of amputation and arterial reconstruction for chronic critical leg ischaemia (CLI).

DESIGN

A 5 year follow-up study of patients with primary intervention for CLI.

SETTING

One regional and two district hospitals serving a defined population.

MATERIAL

One hundred and seventeen consecutive patients undergoing reconstructive arterial surgery or amputation for CLI.

CHIEF OUTCOME MEASURES

Additional procedures, treatment resources and costs related to the treatment of CLI.

MAIN RESULTS

Reconstruction patients needed frequent reinterventions due to graft problems, additional CLI symptoms and revisions of ischaemic tissue. The mean costs for a reconstruction were 240,000 FIM/patient and 70,000 FIM/survival year including costs for later amputations. Patients with a reconstruction without later amputation had costs of 175,000/ patient and 47,000/survival year. A reconstruction with a later amputation had the highest costs, 402,000/patient and 148,000/survival year. Contralateral leg ischaemia caused a new intervention in 25% of all patients. For non-institutionalised patients an amputation resulted in institutional treatment in over 20% of the remaining surviving days with a cost of 313,000 FIM/patient and 150,000 FIM/survival year. CLI in institutionalised patients with a primary amputation had a short stay in hospital, needed little additional resources and caused only low additional costs.

CONCLUSIONS

Costs for a reconstruction in potentially mobile, independently living patients with CLI is similar to those of an amputation. It often demands repeated interventions to achieve good results. On a cost/survival year basis, amputations carry higher costs. For institutionalised, immobile patients with CLI an amputation is often the only possible and cheapest treatment.

Cost-efficacy issues in the treatment of peripheral vascular disease: primary amputation or revascularization for limb-threatening ischemia

Controlling rising health care costs represents a major challenge to our society. Due to the aging of the population and the increasing number of patients with vascular disease, vascular specialists will be under mounting pressure by the managed care industry to provide the most cost-effective care for these patients. One particular controversy is whether to attempt revascularization in the patient with limb-threatening ischemia or to proceed directly with primary amputation. Although it has been assumed that the operative risk for revascularization procedures is high in elderly patients with a severely ischemic limb, mortality rates in the sickest patients are actually higher for amputation. It is also incorrect to assume that the duration of hospitalization is shorter for patients undergoing amputation than for patients undergoing revascularization. For both types of procedures, it is complications that prolong the length of hospital stay, and the rate of secondary amputation following a revascularization attempt is low (8.5%), compared with the rate of operative revision in patients following primary below-knee amputation (23%). The costs for revascularization and primary amputation are similar when the costs of a prosthesis and rehabilitative therapy are included in the calculations for amputation. The rationale for primary amputation assumes that patients will ambulate successfully with a prosthesis; however, many do not, and thus costs for institutionalization must be included in the equation. Long-term costs following revascularization were $28,374 in patients with a viable limb, compared with $56,809 in those undergoing secondary revascularization. The key to minimizing health care costs in this population is careful patient selection for initial revascularization, with aggressive long-term surveillance to ensure graft patency and limb viability.