The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia

Abstract

Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.

Keywords

amputation - peripheral artery disease - chronic limb-threatening ischemia - artery - risk factors - end-stage renal disease

Publikationsverlauf

Artikel online veröffentlicht:
14. Mai 2020

• References

• 1 Conte MS, Bradbury AW, Kolh P. , et al; GVG Writing Group. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69 (6S): 3S-125S, e40
• 2 Almasri J, Adusumalli J, Asi N. , et al. A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg 2019; 58 (1S): S110-S119
• 3 Sumpio BE, Armstrong DG, Lavery LA, Andros G. ; SVS/APMA writing group. The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association. J Vasc Surg 2010; 51 (06) 1504-1506
• 4 Mills Sr JL, Conte MS, Armstrong DG. , et al; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59 (01) 220-234.e1–2
• 5 Harris CM, Albaeni A, Thorpe RJ, Norris KC, Abougergi MS. Racial factors and inpatient outcomes among patients with diabetes hospitalized with foot ulcers and foot infections, 2003-2014. PLoS One 2019; 14 (05) e0216832
• 6 Goldberg JB, Goodney PP, Cronenwett JL, Baker F. The effect of risk and race on lower extremity amputations among Medicare diabetic patients. J Vasc Surg 2012; 56 (06) 1663-1668
• 7 Rowe VL, Lee W, Weaver FA, Etzioni D. Patterns of treatment for peripheral arterial disease in the United States: 1996-2005. J Vasc Surg 2009; 49 (04) 910-917
• 8 Jones WS, Patel MR, Dai D. , et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. Am Heart J 2013; 165 (05) 809-815, 815.e1
• 9 Rodríguez Pérez MDC, Chines C, Pedrero García AJ. , et al. Major amputations in type 2 diabetes between 2001 and 2015 in Spain: regional differences. BMC Public Health 2020; 20 (01) 54
• 10 Claessen H, Narres M, Haastert B. , et al. Lower-extremity amputations in people with and without diabetes in Germany, 2008-2012—an analysis of more than 30 million inhabitants. Clin Epidemiol 2018; 10: 475-488
• 11 Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008; 31 (01) 99-101
• 12 Karakoc A, Ersoy RU, Arslan M, Toruner FB, Yetkin I. Change in amputation rate in a Turkish diabetic foot population. J Diabetes Complications 2004; 18 (03) 169-172
• 13 Moxey PW, Gogalniceanu P, Hinchliffe RJ. , et al. Lower extremity amputations—a review of global variability in incidence. Diabet Med 2011; 28 (10) 1144-1153
• 14 Unwin N. Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. Br J Surg 2000; 87 (03) 328-337
• 15 Mustapha JA, Fisher Sr BT, Rizzo JA. , et al. Explaining racial disparities in amputation rates for the treatment of peripheral artery disease (PAD) using decomposition methods. J Racial Ethn Health Disparities 2017; 4 (05) 784-795
• 16 Lefebvre KM, Lavery LA. Disparities in amputations in minorities. Clin Orthop Relat Res 2011; 469 (07) 1941-1950
• 17 Feinglass J, Rucker-Whitaker C, Lindquist L, McCarthy WJ, Pearce WH. Racial differences in primary and repeat lower extremity amputation: results from a multihospital study. J Vasc Surg 2005; 41 (05) 823-829
• 18 Arya S, Binney Z, Khakharia A. , et al. Race and socioeconomic status independently affect risk of major amputation in peripheral artery disease. J Am Heart Assoc 2018; 7 (02) e007425
• 19 Perrin BM, Allen P, Gardner MJ. , et al. The foot-health of people with diabetes in regional and rural Australia: baseline results from an observational cohort study. J Foot Ankle Res 2019; 12: 56
• 20 West M, Chuter V, Munteanu S, Hawke F. Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians. J Foot Ankle Res 2017; 10: 48
• 21 Narres M, Kvitkina T, Claessen H. , et al. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: a systematic review. PLoS One 2017; 12 (08) e0182081
• 22 Ólafsdóttir AF, Svensson A-M, Pivodic A. , et al. Excess risk of lower extremity amputations in people with type 1 diabetes compared with the general population: amputations and type 1 diabetes. BMJ Open Diabetes Res Care 2019; 7 (01) e000602
• 23 Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012; 55 (07) 1919-1925
• 24 Uçkay I, Aragón-Sánchez J, Lew D, Lipsky BA. Diabetic foot infections: what have we learned in the last 30 years?. Int J Infect Dis 2015; 40: 81-91
• 25 Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293 (02) 217-228
• 26 Suckow BD, Newhall KA, Bekelis K. , et al. Hemoglobin A1c testing and amputation rates in Black, Hispanic, and White medicare patients. Ann Vasc Surg 2016; 36: 208-217
• 27 Kaminski MR, Raspovic A, McMahon LP. , et al. Risk factors for foot ulceration and lower extremity amputation in adults with end-stage renal disease on dialysis: a systematic review and meta-analysis. Nephrol Dial Transplant 2015; 30 (10) 1747-1766
• 28 Gilhotra RA, Rodrigues BT, Vangaveti VN, Malabu UH. Prevalence and risk factors of lower limb amputation in patients with end-stage renal failure on dialysis: a systematic review. Int J Nephrol 2016; 2016: 4870749
• 29 Baubeta Fridh E, Andersson M, Thuresson M. , et al. Editor's Choice—impact of comorbidity, medication, and gender on amputation rate following revascularisation for chronic limb threatening ischaemia. Eur J Vasc Endovasc Surg 2018; 56 (05) 681-688
• 30 Egorova NN, Guillerme S, Gelijns A. , et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg 2010; 51 (04) 878-885, 885.e1
• 31 Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. J Vasc Surg 2015; 61 (01) 162-169
• 32 Benoit E, O'Donnell Jr TF, Kitsios GD, Iafrati MD. Improved amputation-free survival in unreconstructable critical limb ischemia and its implications for clinical trial design and quality measurement. J Vasc Surg 2012; 55 (03) 781-789
• 33 Mustapha JA, Katzen BT, Neville RF. , et al. Determinants of long-term outcomes and costs in the management of critical limb ischemia: a population-based cohort study. J Am Heart Assoc 2018; 7 (16) e009724
• 34 Mozaffarian D, Benjamin EJ, Go AS. , et al; Writing Group Members; American Heart Association Statistics Committee; Stroke Statistics Subcommittee. Heart disease and stroke statistics-2016 update: a report from the American Heart Association. Circulation 2016; 133 (04) e38-e360
• 35 Teraa M, Conte MS, Moll FL, Verhaar MC. Critical limb ischemia: current trends and future directions. J Am Heart Assoc 2016; 5 (02) e002938
• 36 Sheahan MG, Hamdan AD, Veraldi JR. , et al. Lower extremity minor amputations: the roles of diabetes mellitus and timing of revascularization. J Vasc Surg 2005; 42 (03) 476-480
• 37 La Fontaine J, Reyzelman A, Rothenberg G, Husain K, Harkless LB. The role of revascularization in transmetatarsal amputations. J Am Podiatr Med Assoc 2001; 91 (10) 533-535
• 38 Abou-Zamzam Jr AM, Teruya TH, Killeen JD, Ballard JL. Major lower extremity amputation in an academic vascular center. Ann Vasc Surg 2003; 17 (01) 86-90
• 39 Slovut DP, Sullivan TM. Critical limb ischemia: medical and surgical management. Vasc Med 2008; 13 (03) 281-291
• 40 Baghdasaryan PA, Bae JH, Yu W. , et al. “The renal foot” —angiographic pattern of patients with chronic limb threatening ischemia and end-stage renal disease. Cardiovasc Revasc Med 2020; 21 (01) 118-121
• 41 Desai TR, Meyerson SL, Skelly CL. , et al. Patency and limb salvage after infrainguinal bypass with severely compromised (“blind”) outflow. Arch Surg 2001; 136 (06) 635-642
• 42 Biancari F, Albäck A, Ihlberg L, Kantonen I, Luther M, Lepäntalo M. Angiographic runoff score as a predictor of outcome following femorocrural bypass surgery. Eur J Vasc Endovasc Surg 1999; 17 (06) 480-485
• 43 Higashimori A, Iida O, Yamauchi Y. , et al; OLIVE Investigators. Outcomes of one straight-line flow with and without pedal arch in patients with critical limb ischemia. Catheter Cardiovasc Interv 2016; 87 (01) 129-133
• 44 Kawarada O, Yasuda S, Huang J. , et al. Contemporary infrapopliteal intervention for limb salvage and wound healing: harmonization of revascularization and wound management. Circ J 2014; 78 (07) 1540-1549
• 45 Oresanya L, Zhao S, Gan S. , et al. Functional outcomes after lower extremity revascularization in nursing home residents: a national cohort study. JAMA Intern Med 2015; 175 (06) 951-957
• 46 Bertges DJ, Neal D, Schanzer A. , et al; Vascular Quality Initiative. The vascular quality initiative cardiac risk index for prediction of myocardial infarction after vascular surgery. J Vasc Surg 2016; 64 (05) 1411-1421.e4
• 47 Suckow BD, Goodney PP, Cambria RA. , et al; Vascular Study Group of New England. Predicting functional status following amputation after lower extremity bypass. Ann Vasc Surg 2012; 26 (01) 67-78
• 48 Schanzer A, Goodney PP, Li Y. , et al; Vascular Study Group of Northern New England. Validation of the PIII CLI risk score for the prediction of amputation-free survival in patients undergoing infrainguinal autogenous vein bypass for critical limb ischemia. J Vasc Surg 2009; 50 (04) 769-775 , discussion 775
• 49 Robinson WP, Loretz L, Hanesian C. , et al. Society for Vascular Surgery Wound, Ischemia, foot infection (WIfI) score correlates with the intensity of multimodal limb treatment and patient-centered outcomes in patients with threatened limbs managed in a limb preservation center. J Vasc Surg 2017; 66 (02) 488-498.e2
• 50 Allie DE, Hebert CJ, Lirtzman MD. , et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI. EuroIntervention 2005; 1 (01) 75-84
• 51 Goodney PP, Travis LL, Nallamothu BK. , et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes 2012; 5 (01) 94-102
• 52 Cruz CP, Eidt JF, Capps C, Kirtley L, Moursi MM. Major lower extremity amputations at a Veterans Affairs hospital. Am J Surg 2003; 186 (05) 449-454
• 53 Goodney PP, Nolan BW, Schanzer A. , et al; Vascular Study Group of Northern New England. Factors associated with amputation or graft occlusion one year after lower extremity bypass in northern New England. Ann Vasc Surg 2010; 24 (01) 57-68
• 54 Klaphake S, de Leur K, Mulder PG. , et al. Mortality after major amputation in elderly patients with critical limb ischemia. Clin Interv Aging 2017; 12: 1985-1992
• 55 Faglia E, Clerici G, Clerissi J. , et al. Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study. Diabetes Care 2009; 32 (05) 822-827
• 56 Suckow BD, Goodney PP, Nolan BW. , et al. Domains that determine quality of life in vascular amputees. Ann Vasc Surg 2015; 29 (04) 722-730
• 57 Columbo JA, Davies L, Kang R. , et al. Patient experience of recovery after major leg amputation for arterial disease. Vasc Endovascular Surg 2018; 52 (04) 262-268
• 58 Schmidt BM, Holmes CM, Ye W, Pop-Busui R. A tale of two eras: mining big data from electronic health records to determine limb salvage rates with podiatry. Curr Diabetes Rev 2019; 15 (06) 497-502
• 59 Wang C, Mai L, Yang C. , et al. Reducing major lower extremity amputations after the introduction of a multidisciplinary team in patient with diabetes foot ulcer. BMC Endocr Disord 2016; 16 (01) 38
• 60 Sumpio BE, Aruny J, Blume PA. The multidisciplinary approach to limb salvage. Acta Chir Belg 2004; 104 (06) 647-653
• 61 Flores AM, Mell MW, Dalman RL, Chandra V. Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice. J Vasc Surg 2019; 70 (05) 1612-1619
• 62 Chandra V, Glebova NO, Salvo NL, Wu T. Partnerships between podiatrists and vascular surgeons in building effective wound care centers. J Vasc Surg 2017; 66 (03) 902-905
• 63 Armstrong DG, Bharara M, White M. , et al. The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot. Diabetes Metab Res Rev 2012; 28 (06) 514-518
• 64 Joret MO, Osman K, Dean A, Cao C, van der Werf B, Bhamidipaty V. Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease. J Vasc Surg 2019; 70 (03) 806-814
• 65 Ragnarson Tennvall G, Apelqvist J. Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations. Diabetologia 2001; 44 (11) 2077-2087
• 66 Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 2010; 52 (Suppl. 03) 17S-22S
• 67 Ollendorf DA, Kotsanos JG, Wishner WJ. , et al. Potential economic benefits of lower-extremity amputation prevention strategies in diabetes. Diabetes Care 1998; 21 (08) 1240-1245
• 68 Peters CM, de Vries J, Veen EJ. , et al. Is amputation in the elderly patient with critical limb ischemia acceptable in the long term?. Clin Interv Aging 2019; 14: 1177-1185
• 69 Mustapha JA, Katzen BT, Neville RF. , et al. Determinants of long-term outcomes and costs in the management of critical limb ischemia: a population-based cohort study. J Am Heart Assoc 2018; 7 (16) e009724
• 70 Aulivola B, Hile CN, Hamdan AD. , et al. Major lower extremity amputation: outcome of a modern series. Arch Surg 2004; 139 (04) 395-399 , discussion 399
• 71 Columbo JA, Nolan BW, Stucke RS. , et al. Below-knee amputation failure and poor functional outcomes are higher than predicted in contemporary practice. Vasc Endovascular Surg 2016; 50 (08) 554-558
• 72 Taylor SM, Kalbaugh CA, Blackhurst DW. , et al. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg 2005; 42 (02) 227-235
• 73 Robinson K. Amputation in vascular disease. Ann R Coll Surg Engl 1980; 62 (02) 87-91
• 74 Taylor SM, Kalbaugh CA, Cass AL. , et al. “Successful outcome” after below-knee amputation: an objective definition and influence of clinical variables. Am Surg 2008; 74 (07) 607-612 , discussion 612–613
• 75 Vogel TR, Petroski GF, Kruse RL. Impact of amputation level and comorbidities on functional status of nursing home residents after lower extremity amputation. J Vasc Surg 2014; 59 (05) 1323-30.e1
• 76 Peters CML, de Vries J, Lodder P. , et al. Quality of life and not health status improves after major amputation in the elderly critical limb ischaemia patient. Eur J Vasc Endovasc Surg 2019; 57 (04) 547-553
• 77 Pell JP, Donnan PT, Fowkes FGR, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg 1993; 7 (04) 448-451
• 78 Steunenberg SL, Raats JW, Te Slaa A, de Vries J, van der Laan L. Quality of life in patients suffering from critical limb ischemia. Ann Vasc Surg 2016; 36: 310-319
• 79 Davie-Smith F, Coulter E, Kennon B, Wyke S, Paul L. Factors influencing quality of life following lower limb amputation for peripheral arterial occlusive disease: a systematic review of the literature. Prosthet Orthot Int 2017; 41 (06) 537-547
• 80 Williams LH, Miller DR, Fincke G. , et al. Depression and incident lower limb amputations in veterans with diabetes. J Diabetes Complications 2011; 25 (03) 175-182
• 81 Parkes CM. Psycho-social transitions: comparison between reactions to loss of a limb and loss of a spouse. Br J Psychiatry 1975; 127: 204-210
• 82 Raviola CA, Nichter LS, Baker JD, Busuttil RW, Machleder HI, Moore WS. Cost of treating advanced leg ischemia. Bypass graft vs primary amputation. Arch Surg 1988; 123 (04) 495-496
• 83 Barshes NR, Chambers JD, Cohen J, Belkin M. ; Model to Optimize Healthcare Value in Ischemic Extremities 1 (MOVIE) Study Collaborators. Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss. J Vasc Surg 2012; 56 (04) 1015-24.e1
• 84 Mahoney EM, Wang K, Keo HH. , et al; Reduction of Atherothrombosis for Continued Health (REACH) Registry Investigators. Vascular hospitalization rates and costs in patients with peripheral artery disease in the United States. Circ Cardiovasc Qual Outcomes 2010; 3 (06) 642-651
• 85 Barshes NR, Kougias P, Ozaki CK. , et al. Cost-effectiveness of revascularization for limb preservation in patients with marginal functional status. Ann Vasc Surg 2014; 28 (01) 10-17