Major lower extremity amputations at a Veterans Affairs hospital

doi:10.1016/j.amjsurg.2003.07.027

The American Journal of Surgery

Volume 186, Issue 5, November 2003, Pages 449-454

https://doi.org/10.1016/j.amjsurg.2003.07.027 Get rights and content

Abstract

Background

This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years.

Methods

The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001) were retrospectively analyzed. All amputations were performed by members of the vascular surgery department.

Results

Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory.

Conclusions

Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.

Section snippets

Patients and methods

The medical records of all patients on the vascular surgery service who underwent a major lower extremity amputation for vascular pathology over a 7-year period from September 1994 to October 2001 were retrieved from a computerized data base. Two hundred and twenty-nine patients who underwent 296 consecutive major lower extremity amputations at a single VA medical center were identified. All amputations were performed by members of the vascular surgery department. Amputations distal to the

Results

Two hundred and ninety-six consecutive major lower extremity amputations were performed on 229 patients. One hundred and seventy-seven BKAs and 119 AKAs were performed during this period, yielding a BKA to AKA ratio of 1.6. Forty of the patients (17%) eventually required an amputation of their contralateral limb. Twenty-seven (15%) of the BKAs required a subsequent ipsilateral AKA; this subset of patients composes the previously described group 3.

There were 8 female patients and 221 male

Comments

Although some groups have reported a substantial reduction in the number of major amputations associated with the increased use of lower extremity bypass surgery and angioplasty techniques [10], most large population-based studies suggest that major lower extremity amputation rates and their associated mortality have remained relatively unchanged over the past 2 decades [2]. Patients in need of lower extremity amputations represent a high-risk population with multiple comorbidities as is

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The aim of this study was to determine the cumulative incidence of, and the risk factors associated with, contralateral amputation in patients with chronic limb threatening ischaemia (CLTI).
This was a retrospective cohort study of patients with incident unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to CLTI, identified from the National Veterans Affairs Surgical Quality Improvement Program database (2004 – 2014). Thirteen potential pre-operative risk factors for contralateral amputation were considered. A competing risk analysis to estimate the cumulative incidence of contralateral amputation was performed using a Fine-Gray subdistribution hazard model. The effect of risk factors on contralateral amputation was estimated by computing subdistribution hazard ratios (sub-HR) with 95% confidence intervals (CI).
From the database, 7 360 patients met the inclusion criteria. The contralateral amputation risk was 7.7% and was greatest in those who underwent a TF amputation (9.7%), followed by TT (7.4%) and TM amputation (6.6%) (p < .001). Among the 588 contralateral amputations, 50% were at the TF level, 34% at the TT level, and 16% at the TM level. The adjusted risk of contralateral amputation was greater in those who underwent an incident TF amputation or were Black or Hispanic. The factor that contributed to risk of contralateral amputation to the greatest extent was dialysis (sub-HR, 2.3; 95% CI 1.7 – 3.0; p < .001) while those who were obese (compared with underweight) were at lowest risk (0.67; 95% CI 0.46 – 0.97; p = .030).
The one year risk of contralateral amputation in patients with CLTI is related to incident amputation level, medical comorbidities, correlates with race/ethnicity, and body mass index at the time of the incident amputation. The identified risk factors are largely not modifiable; however, they can be used to help identify populations at elevated risk.
Risk factors for failure of limb salvage among veterans with foot ulcers
2022, Foot and Ankle Surgery
Citation Excerpt :
However, despite this research, there remains a relative dearth of information regarding factors associated with failure of limb salvage for patients who have already developed a foot ulcer and are facing imminent decisions regarding operative treatment including limb salvage vs. amputation. In addition, studies have shown that the incidence of below knee amputations (BKAs) among veterans has remained virtually unchanged over the past 10–20 years [15,16]. Within the authors’ hospital, a multidisciplinary team manages patients treated for foot ulcers, often in patients with diabetes and/or peripheral vascular disease.
There is limited available information to guide early discussions involving limb salvage for patients with non-traumatic foot ulcers. We hypothesized patient, wound and treatment factors identifiable at initial operative treatment would be associated with failure of attempted limb salvage.
We retrospectively assessed United States military veterans treated operatively for non-traumatic foot ulcers at a Veteran’s Administration (VA) hospital from 2008 to 2018. Cox proportional hazard analysis assessed for independent associations with eventual above ankle amputation.
Limb salvage failed for 52 of 461 patients (11.0%). Univariable associations included initial wound area ≥1 cm (p < .001), immediate TMA (p < .001), diagnosis of PVD (p < .001) or diabetes (p = .005), nonpalpable pulse (p = .006), CKD (p = .023), creatine ≥ 1.5 (p = .004), and HgA1c ≥ 6.2 (p < .001). Independent associations consisted of initial wound area ≥1 cm (HR 6.0, 95% CI 1.4–25.1, p = .014), immediate TMA (HR 3.5, 95% CI 1.9–6.4, p < .001), and PVD (HR 3.5, 95% CI 1.6–7.5, p = .001). When <2 risk factors were present, 99.1% and 96.8% retained their hindfoot at 5 and 10 years, respectively. However, this decreased to 87.3% and 80.1% with two risk factors and fell to 63.3% and 43.3% with three risk factors.
Failure of limb salvage was increasingly likely as the number of identified independent risk factors increased. These results may assist in prognostication and shared decision making between patients and providers.
Prognostic, Level III.
Predictive Accuracy of the American College of Surgeons Risk Calculator in Patients Undergoing Major Lower Extremity Amputation
2022, Annals of Vascular Surgery
The American College of Surgeons Risk Calculator (ACS-RC) provides an assessment of a patient's risk of 30-day postoperative complications. The Surgeon Adjusted Risk (SAR) parameter of the calculator allows for ad hoc adjustment of risk based on risk factors not considered by the model. This study aims to evaluate the predictive accuracy of the ACS-RC in vascular surgery patients undergoing major lower-extremity amputation (LEA) and identify additional risk factors that warrant use of the SAR parameter.
This is a retrospective study of 298 sequential amputations at a single institution. At the population level, the mean of predicted 30-day outcomes from the ACS-RC with a SAR score of 1 (no adjustment necessary) and 2 (risk somewhat higher than estimate) were compared to the rate of observed outcomes. Predictive accuracy at the individual level was completed using receiver operating curve area under the curve (AUC). Logistic regression with respect to mortality was performed over variables not considered by the ACS-RC. Efficacy of selectively utilizing the SAR parameter in predicting mortality was analyzed with a stratified analysis in which patients with risk factors significant for mortality were assigned increased risk.
At the population level, ACS-RC grossly underpredicted serious complications, SSI, VTE, and unplanned RTOR, while overpredicting mortality and cardiac complications. At the individual level, SAR1 was more predictive for serious complications (AUC = 0.624), SSI (AUC = 0.610), and unplanned RTOR (AUC = 0.541). Conversely, SAR2 was more predictive for mortality (AUC = 0.709), cardiac complications (AUC = 0.561), and VTE (AUC = 0.539). Logistic regression identified history of CVA with a residual deficit (OR = 4.61, P = 0.033) and ischemic rest pain without tissue loss (OR = 4.497, P = 0.047) as independent risk factors for postoperative mortality. Stratified analysis with utilization of the SAR2 based on the 2 independent risk factors improved AUC in predicting mortality (AUC 0.792 from 0.709).
Major LEAs are associated with high perioperative morbidity and mortality. In a veteran population, the ACS-RC showed mixed predictability at the population level and fair predictability at the individual level with regards to postoperative outcomes. Rest pain without tissue loss and history of CVA with residual deficit were identified as risk factors for postoperative mortality. Although ad hoc adjustment with the subjective SAR modifier based on the presence of these 2 risk factors increased the calculator's accuracy, this study highlights some potential limitations of the ACS-RC when applied to vascular surgery patients undergoing major LEA.
Long Term Survival and Limb Salvage in Patients With Non-Revascularisable Chronic Limb Threatening Ischaemia
2021, European Journal of Vascular and Endovascular Surgery
The aim of this study was to provide long term survival and limb salvage rates for patients with non-revascularisable (NR) chronic limb threatening ischaemia (CLTI).
This was a retrospective review of prospectively collected data, derived from a randomised controlled trial (JUVENTAS) investigating the use of a regenerative cell therapy. Survival and limb salvage of the index limb in CLTI patients without viable options for revascularisation at inclusion were analysed retrospectively. The primary outcome was amputation free survival, a composite of survival and limb salvage, at five years after inclusion in the original trial.
In 150 patients with NR-CLTI, amputation free survival was 43% five years after inclusion. This outcome was driven by an equal rate of all cause mortality (35%) and amputation (33%). Amputation occurred predominantly in the first year. Furthermore, 33% of those with amputation subsequently died within the investigated period, with a median interval of 291 days.
Five years after the initial need for revascularisation, about half of the CLTI patients who were deemed non-revascularisable survived with salvage of the index limb. Although the prospects for these high risk patients are still poor, under optimal medical care, amputation free survival seems comparable with that of revascularisable CLTI patients, while the major amputation rate within one year, especially among NR-CLTI patients with ischaemic tissue loss, is very high.
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Below-knee amputation remains the most common level of amputation in patients with lower extremity gangrene and critical limb ischemia. Failure to heal, requiring additional operative debridement or conversion to an above-knee amputation remains a significant cause of patient morbidity. There remains no definitive diagnostic test that can accurately predict healing of the amputation site. We report a case utilizing a hybrid technique of retrograde transamputation revascularization via balloon angioplasty. This proximal, retrograde approach allows for relatively easy crossing and treatment of the infrainguinal chronic total occlusions (CTOs), improving arterial inflow for optimal wound healing.
Self-Management to Improve Function After Amputation: A Randomized Controlled Trial of the VETPALS Intervention
2021, Archives of Physical Medicine and Rehabilitation
To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system.
Randomized controlled trial with masked outcome assessment.
Five Veterans Affairs medical centers geographically dispersed across the United States.
147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147).
Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested.
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Scientific paperMajor lower extremity amputations at a Veterans Affairs hospital

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Comments

Ann Vasc Surg

Surgery

J Vasc Surg

J Vasc Surg

Ann Vasc Surg

J Vasc Surg

Scientific paper
Major lower extremity amputations at a Veterans Affairs hospital