Elsevier

Cardiovascular Surgery

Volume 11, Issue 2, April 2003, Pages 121-123
Cardiovascular Surgery

Amputation for acute ischaemia is associated with increased comorbidity and higher amputation level

https://doi.org/10.1016/S0967-2109(02)00151-5Get rights and content

Abstract

Background: There is some evidence that the early outcome of major amputation is worse after failed thromboembolectomy, but the risk factors and results of amputation done for acute ischaemia have never been compared with those for chronic ischaemia in a large series of patients.

Method: Retrospective review of 30 day outcome for all 322 primary amputations done for arterial disease during 1992–8. There were 286 patients (163 male; median age 76 years) who had 270 amputations for chronic ischaemia and 52 for acute ischaemia.

Results: The acute group had higher prevalences of cardiac disease (48% versus 29%—p<0.02), limiting pulmonary disease (27% versus 13%—p<0.02) and ASA grades 4 and 5 (27% versus 14%—p<0.05). Amputation below the knee was less common after acute ischaemia (31% versus 60%—p<0.001). There were trends towards more revisions (19% versus 11%) and higher mortality (25% versus 19%) in the acute group but neither reached statistical significance.

Conclusion: Patients having major amputations for acute ischaemia have higher levels of pre-existing comorbidity than those with chronic ischaemia and are twice as likely to require amputation above the knee. They should be managed as a particularly high risk group.

Introduction

Most major lower limb amputations are done for rest pain or tissue loss caused by clinically longstanding chronic arterial disease, but a proportion of patients lose their legs as a result of acute ischaemia. Almost all reported series of vascular amputees make no distinction between these groups of patients, although there are two reports [1], [2] which grouped vascular patients on the basis of indications for limb loss. After failed thromboembolectomy for acute ischaemia both reported a higher incidence of amputations above the knee; one reported higher revision rates [1]; and mortality seemed higher [2]. Numbers of amputations for failed thromboembolectomy were small (19 [1] and 11 [2]). We could find no other reports comparing patient profiles and outcomes for acute and chronic ischaemia.

This study examined the early results in a large cohort of amputees with specific regard to limbs presenting with acute ischaemia, compared with those amputated as a result of chronic arterial disease.

Section snippets

Patients and methods

During the seven years 1992–8, 377 primary lower limb amputations were done for vascular disease on our unit, and details of all 334 patients and their operations had been recorded on a database at the time of surgery. This study was done by interrogation of the database and subsequent case note review, using a detailed machine readable proforma (Formic Ltd., Units 25–28 Ransome’s Dock, London SW11 4NP).

Case notes were missing for 22 (7%) patients (23 amputated limbs) and 27 patients had their

Results

The 52 limbs presenting with acute ischaemia were associated with higher levels of comorbidity than the 270 amputated for chronic ischaemia. Specifically (Table 1) there were significantly higher prevalences of limiting cardiac disease (48% versus 29%—p<0.02) and limiting chest problems (27% versus 13%—p<0.02) in the acute group. A significantly higher proportion of acutely ischaemic limbs were associated with ASA grades 4 and 5 (27%) than chronically ischaemic limbs (14%)—p<0.05.

With regard to

Discussion

The only two previous reports comparing amputation for acute ischaemia with other vascular amputations used failed thromboembolectomy as their marker for acute cases (although Ellitsgaard et al. [2] also identified amputations done for septicaemia due to gangrene—emergencies indeed, but not usually due to acute ischaemia). Both described patients from the early 1980s, when an attempt at embolectomy was often done unselectively for limbs presenting with acute ischaemia. Larsson and Risberg [1]

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  • N. Ellitsgaard et al.

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