Title: A Prospective Analysis of Critical Limb Ischemia: Factors Leading to Major Primary Amputation versus Revascularization
Authors: Ahmed M. Abou-Zamzam Jr., Nephtali R. Gomez, Afshin Molkara, Jim E. Banta, Theodore H. Teruya, J. David Killeen, and Christian Bianchi
Source: Annals of Vascular Surgery 2007, Article in Press
PODIATRIC RELEVANCE:
Primary major amputations (above knee or below knee) continue to be performed at an alarming rate even in the face of advances of revascularization. Podiatrists are often on the front lines in seeing the devastating effects of comorbid patients with limb threatening disease. The authors set out to evaluate the specific factors leading to either amputation or revascularization. They hypothesized that not only patient comorbidites, but also the system of health care delivery affected the treatment of patients with critical limb ischemia (CLI).
METHODS:
Prospective analysis of patients presenting with CLI (ischemic rest pain, ulceration, and/or gangrene) was undertaken to determine whether patient specific factor or healthcare delivery factors i.e. system related influenced treatment with primary amputation versus lower extremity revascularization (LER). Patient related factors were age, gender, race/ethnicity, coronary artery disease, cerebrovasculoar disease, tobacco use, diabetes, end stage renal disease, hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living environment and ambulatory status). System related factors included time of onset of CLI to vascular surgery evaluation and type of insurance (managed care and other insurance). Univariate and multivariate analyses were utilized.
RESULTS:
A total of 224 patients presented with CLI between March 1, 2001 and March 1, 2005. Patients were treated with primary amputation in 43% and revascularization in 57%. Univariate analysis displayed non/white race, DM ESRD, major tissue loss, dependent living, and non-ambulatory status as significant predictors of amputation versus revascularization. Multivariate analyses displayed, major tissue loss, ESRD, DM and non-ambulatory status remained independent predictors of amputation versus revascularization. System related factors reveled a mean of 8.6 weeks of time to vascular surgery evaluation (7.1 amputations versus 9.3 revascularization). 44% of all cases precluded limb salvage secondary to extensive infection/gangrene.
COMMENTS:
In this prospective analysis of CLI, treatment of this devastating disease process is determined by patient specific factors and does not appear to be adversely influence by system related factors. Future efforts towards limb salvage must focus on aggressive treatment of all medical comorbidities to prevent the late complications of CLI. Recognition of early changes within the spectrum of CLI must be referred to the vascular specialist immediately.
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Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.