Lower Extremity Amputations

Shah, Samir K.; Bena, James; Allemang, Matthew T.; Kelso, Rebecca; Clair, Daniel G.; Vargas, Lina; Kashyap, Vikram S.

doi:10.1177/1538574413503715

Cited by 58 publications

(20 citation statements)

References 21 publications

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“…The male predominance of 61.4% in our sample is consistent with other reports [8, 9, 11, 15, 16, 25, 27–29]. The mean age of the population in this study was 62.9 years, which is relatively younger than that of other study populations in the literature [8–11, 15, 17, 27, 30, 31].…”

Section: Discussionsupporting

confidence: 90%

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

et al. 2019

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BackgroundWe 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.MethodsClinical 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.ResultsThe 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.ConclusionsIn 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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Section: Discussionsupporting

confidence: 90%

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

et al. 2019

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“…Our IHM of 10.0% is consistent with previously reported data ranging from 7% to 12.4% [7, 10, 30–33]. Investigation of underlying influences from health services, surgical decisions and patient motivations behind decisions to amputate might help to explain some of the differences in post-operative mortality rates between studies [34].…”

Section: Discussionsupporting

confidence: 90%

“…Shah et al demonstrated that several independent factors were detrimental to survival (at 24 months) including chronic obstructive pulmonary disease (hazard ratio [HR] 1.82, P = 0.002), dialysis dependence (HR 2.50, P < 0.001), high cardiac risk (HR 2.20, P < 0.001), and guillotine amputation (HR 2.49, P = 0.004) [33]. …”

Section: Discussionmentioning

confidence: 99%

Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks

López‐de‐Andrés

Hernández‐Barrera

López³

et al. 2016

BMC Med Res Methodol

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BackgroundOutcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain.MethodsWe design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients. Main outcome measures: Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index.ResultsFrom 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3–93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266).ConclusionsElixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female sex, congestive heart failure, and renal failure are strong predictors of mortality in these patients.

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“…30 Only 10.4% of the LIBERTY RC5-6 patients had a major amputation at 1 yearmuch lower than the 22% to 67% 5,31-34 primary major amputation rates seen in the literature for CLI patients that did not receive endovascular intervention (Figure 4). 35 The mortality rate in LIBERTY RC5-6 patients was 13.3% at 1 year, very comparable to the outpatient study where the death rate was 11.4% for the entire cohort 29 and much lower than the 30% 1-year mortality rate in a retrospective US study 36 of patients who underwent lower extremity amputation. This rate is very similar though to the mortality rate in a large German retrospective study, 27 where 34.2% of the RC6 patients died within the first 12 months after index hospitalization.…”

Section: Wound Healing On Target Limbmentioning

confidence: 65%

<p>One-Year Outcomes of Peripheral Endovascular Device Intervention in Critical Limb Ischemia Patients: Sub-Analysis of the LIBERTY 360 Study</p>

Mustapha¹,

Igyarto²,

O’Connor³

et al. 2020

VHRM

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Background: High-risk patients with advanced peripheral artery disease (PAD), including critical limb ischemia (CLI), are often excluded from peripheral endovascular device intervention clinical trials, leading to difficulty in translating trial results into real-world practice. There is a need for prospectively assessed studies to evaluate peripheral endovascular device intervention outcomes in CLI patients. Methods: LIBERTY 360 is a prospective, observational, multi-center study designed to evaluate the procedural and long-term clinical outcomes of peripheral endovascular device intervention in real-world patients with symptomatic lower-extremity PAD. One thousand two hundred and four patients were enrolled and stratified based on Rutherford Classification (RC): RC2-3 (N=501), RC4-5 (N=603), and RC6 (N=100). For this sub-analysis, RC5 and RC6 patients (RC5-6; N=404) were pooled and 1-year outcomes were assessed. Results: Procedural complications rarely (1.7%) resulted in post-procedural hospitalization and 89.1% of RC5-6 patients were discharged to home. Considering the advanced disease state in RC5-6 patients, there was a high freedom from 1-year major adverse event rate of 65.5% (defined as target vessel revascularization, death to 30 days, and major target limb amputation). At 1 year, freedom from major amputation was 89.6%. Wounds identified at baseline on the target limb had completely healed in 172/243 (70.8%) of the RC5-6 subjects by 1 year. Additionally, the overall quality of life, as measured by VascuQoL, improved from baseline to 1 year. Conclusion: LIBERTY investigated real-world PAD patients with independent oversight of outcomes. This analysis of LIBERTY RC5-6 patients demonstrates that peripheral endovascular device intervention can be successful in CLI patients, with low rates of major amputation and improvement in wound healing and quality of life through 1-year follow-up. LIBERTY 360, https://clinicaltrials.gov/ct2/show/NCT01855412, ClinicalTrials.gov Identifier: NCT01855412.

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Lower Extremity Amputations

Cited by 58 publications

References 21 publications

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks

<p>One-Year Outcomes of Peripheral Endovascular Device Intervention in Critical Limb Ischemia Patients: Sub-Analysis of the LIBERTY 360 Study</p>

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