February 24, 2005

Demographic Changes In the Level and Numbers Of Amputees Since the Introduction Of Subintimal Angioplasty -- Influence On Limb Salvage Rates In Lower Limb Critical Ischaemia: A 15-Year Experience

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Abstract 12

Niamh Hynes, MB BCh MCh MRCS, B Mahendran, Jawad Asad, Emmet Andrews, Sherif Tawfik, Don Courtney, Sherif Sultan.
Western Vascular Institute, Galway, Ireland.

Introduction& Aim:
The cost of managing post-amputation patients with critical lower limb ischaemia is twice that of successful limb salvage. Furthermore, rehabilitation rates among amputees are poor, justifying an aggressive revascularisation policy. The aim of the study was to assess the influence of subintimal angioplasty on lower limb amputation rate and level in critically ischaemic limbs.
Materials & Methods:
Between January 1989 and March 2004, 1268 patients were admitted for treatment of lower limb critical ischaemia. 829 patients underwent attempts at revascularisation (bypass 671 and angioplasty 158), while 439 patients had primary amputations. A retrospective analysis of a prospectively maintained vascular registry was performed.
Patients were divided into two groups, those who were admitted prior to the availability of subintimal angioplasty and those treated post introduction of angioplasty. The two groups were compared with regards to age, sex, diabetes mellitus, ASA grade, Rutherford classification and level of disease. Primary endpoints were limb salvage rate, length of hospital stay and 30-day morbidity and mortality.
Results:
The rate of revascularisation increased with the introduction of subintimal angioplasty, from 60% to 82% (p<0.001). The limb salvage rate increased from 48% to 75% (p<0.001). The level of amputation (AKA:BKA) did not vary. 30-day morbidity, mortality and length of hospital stay were significantly lower in the post angioplasty group (p<0.05). Risk of amputation following revascularization procedures was positively associated with type of procedure and diabetic status. Non-insured patients had a higher rate of primary amputation.

	Pre-SIA	Post-SIA
Limb Salvage Rate	48%	75%
AKA:BKA	47%:53%	54%:46%
Length of Hospital Stay (days)	56	32
30-day morbidity	44%	12%
30-day mortality	16%	3%

Conclusions:
Technical advances have resulted in a steadying of amputation numbers despite an ageing population. We failed to demonstrate an extrapolative positive correlation between revascularisation rates, amputation numbers or level. Adoption of SIA resulted in increase in peripheral bypass surgery with no decline in lower-extremity amputations due to increased diagnosis of peripheral vascular disease, expanded indications for procedural interventions and increased number of repeated procedures.