Abstract
Objective
To evaluate systemic and limb ischemic event rates of PAD patients with prior leg
amputation and determine predictors of adverse outcomes.
Methods
The REduction of Atherothrombosis for Continued Health (REACH) Registry provided a
prospective multinational cohort of 7996 outpatients with PAD enrolled from primary
medical clinics in 44 countries in 2003–2004. 1160 patients (14.5%) had a prior leg
amputation at any level. Systemic (myocardial infarction [MI], stroke, cardiovascular
death) and limb (angioplasty, surgery, amputation) ischemic event rates were determined
in a 3-year follow-up.
Results
PAD patients with leg amputations on entry had a 5-fold higher rate of a subsequent
amputation (12.4% vs. 2.4%, P < .001), lower rate of peripheral angioplasty (8.3% vs. 10.7%, P = .005), and similar rates of surgical revascularization procedures compared with PAD
patients without amputation. A nearly 2-fold increase in rates of cardiovascular death
(14.5% vs. 7.7%, P < .001) and all-cause mortality (21.8% vs. 12.6%, P < .001) and an increase in the composite outcome of MI, stroke, cardiovascular death,
or hospitalization (48.7% vs. 40.0%, P < .001) were noted. Recent (≤1 year) amputation was associated with higher rates of
worsening PAD, subsequent lower extremity surgical revascularization procedures, re-amputation,
non-fatal MI, and the composite outcome, including hospitalization. Adverse systemic
and limb ischemic outcomes were similar regardless of amputation level.
Conclusions
Individuals with a history of leg amputations have markedly elevated rates of systemic
and limb-related outcomes. PAD patients with recent ischemic amputation have the highest
risk of adverse events. A history of “minor” ischemic amputation may confer an identical
systemic risk as “major” leg amputation.
Highlights
- We evaluated systemic and limb ischemic event rates of PAD patients with prior leg amputation from the REACH Registry.
- PAD patients with prior amputation have markedly elevated rates of systemic and limb-related outcomes.
- PAD patients with recent ischemic amputation have the highest risk of adverse events.
- A history of minor ischemic amputation may confer an identical systemic risk as
- major leg amputation.
Keywords
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References
- ACC/AHA 2005 Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery. Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation.J Am Coll Cardiol. 2006; 47: 1239-1312
- Inter-society consensus for the management of peripheral arterial disease (TASC II).J Vasc Surg. 2007; : S5-S67
- Do differences in hospital and surgeon quality explain racial disparities in lower extremity vascular amputations?.Ann Surg. 2009; 250: 424-431
- The epidemiology of lower extremity amputations in diabetic individuals.Diabetes Care. 1983; 6: 87-91
- Postoperative and late survival outcomes after major amputation: findings from the Department of Veterans Affairs National Surgical Quality Improvement Program.Surgery. 2001; 130: 21-29
- Epidemiology of lower extremity amputation in centers in Europe. North America and East Asia. The global lower extremity amputation study group.Br J Surg. 2000; 87: 328-337
- Natural history of claudication: long-term serial follow-up study of 1244 claudicants.J Vasc Surg. 2001; 36: 962-970
- Critical limb ischaemia: initial treatment and predictors of amputation-free survival.Eur J Vasc Endovasc Surg. 2012; 43 ([Epub 2011 Oct 15]): 55-61
- Major amputations: clinical patterns and predictors.Semin Vasc Surg. 1999; 12: 154-161
- The role of amputation as an outcome measure in cellular therapy for critical limb ischemia: implications for clinical trial design.J Transl Med. 2011; 9: 165
- Interim analysis results from the RESTORE-CLI, a randomized, double-blind multicenter phase II trial comparing expanded autologous bone marrow-derived tissue repair cells and placebo in patients with critical limb ischemia.J Vasc Surg. 2011; 54: 1032-1041
- Effect of fibroblast growth factor NV1FGF on amputation and death: a randomised placebo-controlled trial of gene therapy in critical limb ischaemia.Lancet. 2011; 377: 1929-1937
- Natural history of angina pectoris in the Framingham study: prognosis and survival.Am J Cardiol. 1972; 29: 154-163
- Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee.Circulation. 2009; 119: e21-e181
- Transient ischemic attack: definitions and clinical presentations.Ann Emerg Med. 2008; 52: S7-S16
- Risk factors for amputation in patients with diabetes mellitus. A case-control study.Ann Intern Med. 1992; 117: 97-105
- Identifying cause for advancement to amputation in patients with diabetes: the role of medical care and patient compliance.Wounds. 2005; 17 (Available at: http://www.woundsresearch.com/article/3756): 32-36
- Long-term prognosis of diabetic patients with critical limb ischemia: a population-based cohort study.Diabetes Care. 2009; 32 ([erratum in: Diabetes Care 2009;32(7):1355]): 822-827
- Critical limb ischemia.J Vasc Surg. 2010; 51: 230-241
- The morbidity and mortality following a diagnosis of peripheral arterial disease: long-term follow-up of a large database.BMC Cardiovasc Disord. 2005; 5: 14
- Surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome.J Vasc Surg. 2007; 45: 751-761
- International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis.JAMA. 2006; 295: 180-189
- One-year cardiovascular event rates in outpatients with atherothrombosis.JAMA. 2007; 297: 1197-1206
- Survival following lower-limb amputation in a veteran population.J Rehabil Res Dev. 2001; 38: 341-345
- National health care costs of peripheral arterial disease in the Medicare population.Vasc Med. 2008; 13: 209-215
- One-year costs in patients with a history of or at risk for atherothrombosis in the United States.Circ Cardiovasc Qual Outcomes. 2008; 1: 38-45
- The incidence and health economic burden of ischemic amputation in Minnesota, 2005–2008.Prev Chronic Dis. 2011; 8: A141
- Lower extremity amputation prevention in Singapore: economic analysis of results.Singapore Med J. 2011; 52: 662-668
- Basic data related to amputations.Ann Vasc Surg. 1991; 5: 202-207
- Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. The Global Lower Extremity Amputation Study Group.Br J Surg. 2000; 87: 328-337
- Cardiovascular risk factor control and outcomes in peripheral artery disease patients in the Reduction of Atherothrombosis for Continued Health (REACH) Registry.Atherosclerosis. 2009; 204: e86-e92
- Mortality in diabetic and nondiabetic patients after amputations performed from 1990 to 1995: a 5-year follow-up study.Diabetes Care. 2004; 27: 1598-1604
- Major lower extremity amputations at a Veterans Affairs hospital.Am J Surg. 2003; 186: 449-454
- Major lower extremity amputation: outcome of a modern series.Arch Surg. 2004; 139: 395-399
- Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients.J Vasc Surg. 2005; 42: 227-235
- Unchanged incidence of lower-limb amputations in a German city, 1990–1998.Diabetes Care. 2001; 24: 855-859
- Mortality of first-time amputees in diabetics: a 10-year observation.Diabetes Res Clin Pract. 2009; 83: 126-131
- Survival after lower extremity amputation.J Am Coll Surg. 2004; 199: 394-402
- New ulceration, new major amputation, and survival rates in Diabetic Subject Hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up.Diabetes Care. 2001; 24: 78-83
- Comparison of peripheral arterial construction in diabetic and non-diabetic patients: a prospective clinic-based study.Diab Res Clin Pract. 2001; 53: 129-136
- Evidence of suboptimal management of cardiovascular risk in patients with type 2 diabetes mellitus and symptomatic atherosclerosis.Canad Med Assoc J. 2004; 171: 1189-1192
Article info
Publication history
Published online: February 10, 2012
Accepted:
January 2,
2012
Received in revised form:
November 16,
2011
Received:
July 10,
2011
Identification
Copyright
© 2012 Elsevier Ireland Ltd. Published by Elsevier Inc. All rights reserved.
