A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation

Stern, Jordan R.; Wong, Chi Song; Yerovinkina, Marina; S, Spindler; See, Ashley S.; Panjaki, Samira; Loven, Sarah L.; D’Andrea, Rick F.; Nowygrod, Roman

doi:10.1016/j.avsg.2016.12.015

Cited by 158 publications

(128 citation statements)

References 26 publications

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“…This is an important finding because persistent, severe limb ischaemia threatens limb viability and can lead to amputation, which in turn increases the risk of major adverse cardiovascular events. 19 Furthermore, major amputation is associated with a 50% risk of mortality in the year after the procedure 27,28 and any therapy that can reduce a patient's risk of developing acute limb ischaemia and major amputation might also reduce their future risk of major adverse cardiovascular events and mortality. 20 Patients with peripheral artery disease are also at increased risk of bleeding, which is partly explained by their high number of comorbid conditions such as advanced age and renal insufficiency.…”

Section: Discussionmentioning

confidence: 99%

Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial

et al. 2018

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BACKGROUND Patients with peripheral artery disease have an increased risk of cardiovascular morbidity and mortality. Antiplatelet agents are widely used to reduce these complications. METHODS This was a multicentre, double-blind, randomised placebo-controlled trial for which patients were recruited at 602 hospitals, clinics, or community practices from 33 countries across six continents. Eligible patients had a history of peripheral artery disease of the lower extremities (previous peripheral bypass surgery or angioplasty, limb or foot amputation, intermittent claudication with objective evidence of peripheral artery disease), of the carotid arteries (previous carotid artery revascularisation or asymptomatic carotid artery stenosis of at least 50%), or coronary artery disease with an ankle-brachial index of less than 0·90. After a 30-day run-in period, patients were randomly assigned (1:1:1) to receive oral rivaroxaban (2·5 mg twice a day) plus aspirin (100 mg once a day), rivaroxaban twice a day (5 mg with aspirin placebo once a day), or to aspirin once a day (100 mg and rivaroxaban placebo twice a day). Randomisation was computer generated. Each treatment group was double dummy, and the patient, investigators, and central study staff were masked to treatment allocation. The primary outcome was cardiovascular death, myocardial infarction or stroke; the primary peripheral artery disease outcome was major adverse limb events including major amputation. This trial is registered with ClinicalTrials.gov, number NCT01776424, and is closed to new participants. FINDINGS Between March 12, 2013, and May 10, 2016, we ; HR 0·67, 95% CI 0·45-1·00, p=0·05). The median duration of treatment was 21 months. The use of the rivaroxaban plus aspirin combination increased major bleeding compared with the aspirin alone group (77 [3%] of 2492 vs 48 [2%] of 2504; HR 1·61, 95% CI 1·12-2·31, p=0·0089), which was mainly gastrointestinal. Similarly, major bleeding occurred in 79 (3%) of 2474 patients with rivaroxaban 5 mg, and in 48 (2%) of 2504 in the aspirin alone group (HR 1·68, 95% CI 1·17-2·40; p=0·0043). INTERPRETATION Low-dose rivaroxaban taken twice a day plus aspirin once a day reduced major adverse cardiovascular and limb events when compared with aspirin alone. Although major bleeding was increased, fatal or critical organ bleeding was not. This combination therapy represents an important advance in the management of patients with peripheral artery disease. Rivaroxaban alone did not significantly reduce major adverse cardiovascular events compared with asprin alone, but reduced major adverse limb events and increased major bleeding. FUNDING Bayer AG. Methods This was a multicentre, double-blind, randomised placebo-controlled trial for which patients were recruited at 602 hospitals, clinics, or community practices from 33 countries across six continents. Eligible patients had a history of peripheral artery disease of the lower extremities (previous peripheral bypass surgery or angioplasty, limb or foot amputation, i...

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Section: Discussionmentioning

confidence: 99%

Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial

et al. 2018

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“…Many studies have identified preoperative and perioperative factors associated with operative mortality, and the average mortality risk associated with a given amputation level. Average risks, although important in understanding the outcomes of populations, are of limited value in shared amputation decision‐making because they do not provide information about individual‐patient risk.…”

Section: Introductionmentioning

confidence: 99%

Mortality prediction following non-traumatic amputation of the lower extremity

Norvell

Thompson

Boyko

et al. 2019

British Journal of Surgery

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Background: Patients who undergo lower extremity amputation secondary to the complications of diabetes or peripheral artery disease have poor long-term survival. Providing patients and surgeons with individual-patient, rather than population, survival estimates provides them with important information to make individualized treatment decisions. Methods: Patients with peripheral artery disease and/or diabetes undergoing their first unilateral transmetatarsal, transtibial or transfemoral amputation were identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Stepdown logistic regression was used to develop a 1-year mortality risk prediction model from a list of 33 candidate predictors using data from three of five Department of Veterans Affairs national geographical regions. External geographical validation was performed using data from the remaining two regions. Calibration and discrimination were assessed in the development and validation samples. Results: The development sample included 5028 patients and the validation sample 2140. The final mortality prediction model (AMPREDICT-Mortality) included amputation level, age, BMI, race, functional status, congestive heart failure, dialysis, blood urea nitrogen level, and white blood cell and platelet counts. The model fit in the validation sample was good. The area under the receiver operating characteristic (ROC) curve for the validation sample was 0⋅76 and Cox calibration regression indicated excellent calibration (slope 0⋅96, 95 per cent c.i. 0⋅85 to 1⋅06; intercept 0⋅02, 95 per cent c.i. -0⋅12 to 0⋅17). Given the external validation characteristics, the development and validation samples were combined, giving a total sample of 7168. Conclusion: The AMPREDICT-Mortality prediction model is a validated parsimonious model that can be used to inform the 1-year mortality risk following non-traumatic lower extremity amputation of patients with peripheral artery disease or diabetes.

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“…no ipsilateral revasculariza- tion or minor/major LLA prior to the eventual major LLA), but this was not associated with different odds of returning home (10,11,13). Previous studies state that comorbidities, such as cerebrovascular disease (27,34), (congestive) heart disease (5), chronic pulmonary disease (31,34) and end-stage renal disease (9,10,27), are associated with poorer outcomes of survival, ambulation or prosthesis use. Therefore, we expected persons with these conditions to show lower rates of being able to return home, which was not the case in this study.…”

Section: Discussionmentioning

confidence: 90%

“…O ver 90% of lower limb amputations (LLA) in Western European countries are secondary to peripheral arterial disease (PAD) and diabetes mellitus (DM) (1), and may be referred to as "dysvascular" amputations. LLA are categorized as minor or major, the latter defined as amputation through the ankle joint and more proximal levels (2)(3)(4)(5). Major LLA are associated with more disability (6) and higher mortality rates (3) compared with minor LLA.…”

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confidence: 99%

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Return home after dysvascular major amputation of the lower limb: A multicentre observational study in the Netherlands

Fard¹,

Geertzen²,

Dijkstra³

2020

J Rehabil Med

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LAY ABSTRACTPersons undergoing lower limb amputation due to vascular disease and/or diabetes mellitus are typically elderly and medically frail. Most are admitted from home, and approximately one-fifth return home after hospital admission for amputation surgery, especially those with a partner and younger than 65 years. Among those who are unable to return home in the first instance, eventually nearly 4 out of 5 return to independent living within one year after amputation. It should be borne in mind, however, that one-third of persons does not survive up to one year after amputation and that the aforementioned number of people returning home applies only to those who survive the first year. The healthcare system in the Netherlands provides dedicated rehabilitation programmes for elderly patients, with lower intensity training compared with traditional inpatient rehabilitation programmes. In this study, "geriatric rehabilitation" seemed effective in terms of improving the chances of persons' return to home after a dysvascular major amputation of the lower limb.Objective: To report the rates of persons returning home within one year following dysvascular major amputation of the lower limb in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after discharge to care facilities. Design: Retrospective cohort study. Patients: Dysvascular major amputation of the lower limb, n = 382, mean age 71.9 years (standard deviation (SD) 12.5 years), 65% male. Methods: Medical records of all persons undergoing major amputation of the lower limb in 2012-2013 in 12 hospitals in Northern Netherlands were reviewed. Odds ratios (OR) were calculated using multivariate logistic regression. Results: Among persons admitted from home and surviving the hospital admission, 21% returned home, with higher odds of returning home being associated with living with a partner (OR = 2.8, p = 0.006) and younger age (< 65 years). Among those discharged to care and surviving the first year, 77% returned home within one year after amputation, with higher odds being associated with younger age (<75 years) and admission to inpatient rehabilitation (OR = 10.6, p = 0.004) or geriatric rehabilitation in skilled nursing facilities (OR = 3.5, p = 0.030). Conclusion: Four out of 5 persons surviving dysvascular major amputation of the lower limb return home within one year, although a majority requires care in either inpatient rehabilitation or a skilled nursing facilities setting.

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A Meta-analysis of Long-term Mortality and Associated Risk Factors following Lower Extremity Amputation

Cited by 158 publications

References 26 publications

Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial

Rivaroxaban with or without aspirin in patients with stable peripheral or carotid artery disease: an international, randomised, double-blind, placebo-controlled trial

Mortality prediction following non-traumatic amputation of the lower extremity

Return home after dysvascular major amputation of the lower limb: A multicentre observational study in the Netherlands

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