Procedural and 12-month in-hospital costs of primary infra-popliteal bypass surgery, infrapopliteal best endovascular treatment, and major lower limb amputation for chronic limb threatening ischemia.

OBJECTIVE: Chronic limb-threatening ischemia (CLTI) is a growing global problem due to the widespread use of tobacco and increasing prevalence of diabetes. Although the financial consequences are considerable, few studies have compared the relative cost-effectiveness of different CLTI management strategies. The Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL)-2 trial is randomizing patients with CLTI to primary infrapopliteal (IP) vein bypass surgery (BS) or best endovascular treatment (BET) and includes a comprehensive within-trial cost-utility analysis. The aim of this study is to compare over a 12-month time horizon, the costs of primary IP BS, IP best endovascular treatment (BET), and major limb major amputation (MLLA) to inform the BASIL-2 cost-utility analysis. METHODS: We compared procedural human resource (HR) costs and total in-hospital costs for the index admission, and over the following 12-months, in 60 consecutive patients undergoing primary IP BS (n = 20), IP BET (n = 20), or MLLA (10 transfemoral and 10 transtibial) for CLTI within the BASIL prospective cohort study. RESULTS: Procedural HR costs were greatest for BS (BS £2551; 95% confidence interval [CI], £1934-£2807 vs MLLA £1130; 95% CI, £1046-£1297 vs BET £329; 95% CI, £242-£390; P < .001, Kruskal-Wallis) due to longer procedure duration and greater staff requirement. With regard to the index admission, MLLA was the most expensive due to longer hospital stay (MLLA £13,320; 95% CI, £8986-£18,616 vs BS £8714; 95% CI, £6097-£11,973 vs BET £4813; 95% CI, £3529-£6097; P < .001, Kruskal-Wallis). The total cost of the index admission and in-hospital care over the following 12 months remained least for BET (MLLA £26,327; 95% CI, £17,653-£30,458 vs BS £20,401; 95% CI, £12,071-£23,926 vs BET £12,298; 95% CI, £6961-£15,439; P < .001, Kruskal-Wallis). CONCLUSIONS: Over a 12-month time horizon, MLLA and IP BS are more expensive than IP BET in terms of procedural HR costs and total in-hospital costs. These economic data, together with quality of life data from BASIL-2, will inform the calculation of incremental cost-effectiveness ratios for different CLTI management strategies within the BASIL-2 cost-utility analysis.

Long Term Survival and Limb Salvage in Patients With Non-Revascularisable Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to provide long term survival and limb salvage rates for patients with non-revascularisable (NR) chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective review of prospectively collected data, derived from a randomised controlled trial (JUVENTAS) investigating the use of a regenerative cell therapy. Survival and limb salvage of the index limb in CLTI patients without viable options for revascularisation at inclusion were analysed retrospectively. The primary outcome was amputation free survival, a composite of survival and limb salvage, at five years after inclusion in the original trial. RESULTS: In 150 patients with NR-CLTI, amputation free survival was 43% five years after inclusion. This outcome was driven by an equal rate of all cause mortality (35%) and amputation (33%). Amputation occurred predominantly in the first year. Furthermore, 33% of those with amputation subsequently died within the investigated period, with a median interval of 291 days. CONCLUSION: Five years after the initial need for revascularisation, about half of the CLTI patients who were deemed non-revascularisable survived with salvage of the index limb. Although the prospects for these high risk patients are still poor, under optimal medical care, amputation free survival seems comparable with that of revascularisable CLTI patients, while the major amputation rate within one year, especially among NR-CLTI patients with ischaemic tissue loss, is very high.

Outcome of Femoral-popliteal Bypass Procedures in Different Ethnic Groups in England: A Retrospective Analysis of Hospital Episode Statistics.

BACKGROUND: Previous studies, mainly from the United States, have reported worse outcomes from lower limb bypass procedures in ethnic minority populations. Limited nationwide data are available from ethnic minority populations from Europe. The aim of this study is to investigate outcomes from lower limb bypass procedures in ethnic minorities from England. METHODS: We enquired the "Hospital Episode Statistics" database, using ICD-10 codes to identify all cases of femoral-popliteal bypass operations from English NHS Hospitals from 01/01/2006 to 31/12/2015. Every case was followed up for 2 years for subsequent events. The primary outcomes were mortality and major leg amputation. Patients were broadly categorised according to Black, Asian and White ethnicity. Chi-square test was used to the ethnic groups and odds ratios (OR) were calculated using White ethnic group with the largest numbers of participants as a reference category. RESULTS: In the examined 10-year period, 20825 femoral-popliteal bypass procedures (250 of Black, 167 of Asian, and 20.408 of White ethnicity) were recorded. Thirty-day and 2-year mortality were 2.8% and 16.8% with no significant ethnic differences. Patients of Black ethnicity had higher risk of limb loss compared to Whites (23.2% vs. 15.6%, OR = 1.63, 95% confidence interval (CI) 1.21-2.19, P < 0.01). There was no significant difference in amputation rates between Asians and Whites (16.2% vs.. 15.6%, P = 0.94). CONCLUSIONS: Patients of Black ethnicity are at higher risk of limb loss after a femoropopliteal bypass procedure. Further research is needed to identify the causes of this discrepancy.

Racial and ethnic disparities in lower extremity amputation: Assessing the role of frailty in older adults.

BACKGROUND: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications. METHODS: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed. RESULTS: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos. CONCLUSION: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes.

Contemporary Treatment of Popliteal Artery Aneurysms in 14 Countries: A Vascunet Report.

OBJECTIVE: Popliteal artery aneurysm (PAA) is the second most common arterial aneurysm. Vascunet is an international collaboration of vascular registries. The aim was to study treatment and outcomes. METHODS: This was a retrospective analysis of prospectively registered population based data. Fourteen countries contributed data (Australia, Denmark, Finland, France, Hungary, Iceland, Italy, Malta, New Zealand, Norway, Portugal, Serbia, Sweden, and Switzerland). RESULTS: During 2012-2018, data from 10 764 PAA repairs were included. Mean values with between countries ranges in parenthesis are given. The incidence was 10.4 cases/million inhabitants/year (2.4-19.3). The mean age was 71.3 years (66.8-75.3). Most patients, 93.3%, were men and 40.0% were active smokers. The operations were elective in 73.2% (60.0%-85.7%). The mean pre-operative PAA diameter was 32.1 mm (27.3-38.3 mm). Open surgery dominated in both elective (79.5%) and acute (83.2%) cases. A medial surgical approach was used in 77.7%, and posterior in 22.3%. Vein grafts were used in 63.8%. Of the emergency procedures, 91% (n = 2 169, 20.2% of all) were for acute thrombosis and 9% for rupture (n = 236, 2.2% of all). Thrombosis patients had larger aneurysms, mean diameter 35.5 mm, and 46.3% were active smokers. Early amputation and death were higher after acute presentation than after elective surgery (5.0% vs. 0.7%; 1.9% vs. 0.5%). This pattern remained one year after surgery (8.5% vs. 1.0%; 6.1% vs. 1.4%). Elective open compared with endovascular surgery had similar one year amputation rates (1.2% vs. 0.2%; p = .095) but superior patency (84.0% vs. 78.4%; p = .005). Veins had higher patency and lower amputation rates, at one year compared with synthetic grafts (86.8% vs. 72.3%; 1.8% vs. 5.2%; both p < .001). The posterior open approach had a lower amputation rate (0.0% vs. 1.6%, p = .009) than the medial approach. CONCLUSION: Patients presenting with acute ischaemia had high risk of amputation. The frequent use of endovascular repair and prosthetic grafts should be reconsidered based on these results.

Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample.

BACKGROUND: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use. METHODS: Admissions for diabetic lower extremity complications were identified in the 2012 to 2014 National Inpatient Sample using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects. RESULTS: The authors' study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent increase; p < 0.01). CONCLUSIONS: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and use of reconstructive limb salvage procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Medicaid Expansion on Utilization of Vascular Procedures and Rates of Amputation.

BACKGROUND: Although New York's Medicaid expansion increased coverage in 2001, little is known regarding changes in surgical care utilization among patients with vascular disease. We sought to measure the impact of expansion on the rates of both vascular procedures and amputations. MATERIALS AND METHODS: A retrospective analysis was performed using the State Inpatient Databases of New York and Arizona, 1998-2006. Patients aged 18-64 who underwent lower extremity vascular surgery procedures or amputations between 1998 and 2006 were included. Outcomes included rates of total vascular, open vascular, and endovascular procedures, in addition to rates of amputation. A difference-in-difference analysis measured changes in the rates of procedure types, while adjusting for temporal trends in both states. RESULTS: In this cohort (n = 112,624), Medicaid expansion was not associated with a change in mortality (odds ratio 0.92, P = 0.5). Expansion was associated with a lower incidence of total vascular procedures (incidence rate ratio [IRR] 0.65, P < 0.001) and open vascular procedures (IRR 0.92, P = 0.002), but a higher incidence of endovascular procedures (IRR 1.13, P < 0.001). There was no change in the rate of amputations (IRR 1.02, P = 0.58). In patients with chronic limb-threatening ischemia (n = 12,668), expansion was associated with a lower incidence of total procedures (IRR 0.59, P < 0.001) and endovascular procedures (IRR 0.59, P < 0.001) but a higher incidence of amputations (IRR 1.43, P = 0.001) and higher odds of mortality (odds ratio 2.21, P = 0.032). CONCLUSIONS: After Medicaid expansion, the rates of total vascular procedures decreased, with no impact on amputations rates. Furthermore, the utilization of limb-saving procedures in patients with chronic limb-threatening ischemia did not increase.

Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia.

OBJECTIVE: Recent studies suggest similar perioperative outcomes for endovascular and open surgical management of acute limb ischemia (ALI). We sought to describe temporal trends, patient factors, and hospital costs associated with contemporary ALI management. METHODS: We used the weighted National Inpatient Sample to estimate primary ALI cases requiring open or endovascular intervention (2005-2014). We used multivariable regression models to examine temporal trends, patient factors, and hospital costs associated with endovascular-first vs open-first management. RESULTS: Of 116,451 admissions for ALI during the study period, 35.2% were treated by an endovascular-first approach. The percentage of admissions managed with an endovascular-first approach increased over time (P < .001). Independent predictors of endovascular-first management included younger age, male sex, renal insufficiency, and more recent calendar year of admission (P ≤ .02), whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-first management (P ≤ .02). Endovascular-first management had higher mean hospital costs than open-first management ($29,719 vs $26,193; P < .001). After adjustment for patient, hospital, and admission characteristics, there was an increase of $981 in treatment costs per year in the endovascular-first group (95% confidence interval [CI], $571-$1392; P < .001), whereas the costs associated with an open-first approach remained relatively stable over time ($10 per year; 95% CI, -$295 to $315; P = .95; P < .001 for interaction). The risk-adjusted odds of in-hospital major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15; P = .88). CONCLUSIONS: Use of an endovascular-first approach for the treatment of ALI has significantly increased over time. Although major amputation rates are similar for both approaches, the costs associated with an endovascular-first approach are increasing over time, whereas the costs of open surgery have remained stable. The cost-effectiveness of modern ALI management warrants further investigation.

Function and quality of life among primary osteosarcoma survivors in Iran: amputation versus limb salvage.

PURPOSE: This study aimed to evaluate the psychometric properties of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in Iranian osteosarcoma patients and apply this to compare the functional level, quality of life, symptoms and financial burden of the patients who underwent amputation and limb-salvage operations. METHODS: This study was conducted at the main referral orthopedic centers in the southwest of Iran from 2006 to 2016. After complete review of medical records, 48 patients were invited to attend the outpatient clinic and participate in the study via initial telephone interview. All data were entered in the Statistical Package for the Social Sciences version 15.0, and p values <0.05 were considered statistically significant. RESULTS: In total, 48 patients with extremities osteosarcoma completed the study. Of these, 31 had been treated with limb-salvage operation and 17 had undergone amputation. In functioning subscale, all the mean score of items, except social function, were higher in the limb salvage group than the amputee group. The mean scores (SD) of global health and quality of life were 64.5(13.2) and 61.2± 12.4 in the limb salvage and amputee groups, respectively. In the financial impact subscale, the mean score (SD) in the limb salvage group was 68.8± (29.7) compared to 74.5(25.0) in the amputee group. CONCLUSION: Results support the responsiveness of the EORTC QLQ-C30 for Iranian osteosarcoma patients. Applying this questionnaire revealed similar functional outcome, quality of life, symptoms and financial burden between amputation and limb-salvage groups.

[Randomized controlled trial to superficial femoral artery recanalization for lower extremity arteriosclerosis obliterans].

OBJECTIVE: To evaluate the safety and effectiveness of neglecting superficial femoral artery (SFA) recanalization for chronic lower extremity arteriosclerosis obliterans (ASO). METHODS: Thirty-six cases treated for severe stenosis or occlusion of superficial femoral artery resulted from ASO were randomly divided into 2 groups. Twenty of them were treated by endovascular reconstruction of superficial femoral artery and the other 16 cases were not treated with their superficial femoral artery, but were only treated with the accompanied iliac and/or profunda femoral artery lesion. RESULTS: There was no significant difference between the two groups on mean age, gender, ABI before treatment, accompanied diseases, Rutherford classification and trans-atlantic inter-society consensus (TASC) classification (P>0.05).One week after operation, the reconstruction group had better marked effect and total effective rate [75.0% vs.12.5%(P<0.001); 90.0% vs. 37.5%(P=0.001)] and lower no effective rate [10.0% vs. 62.5%(P=0.001)], There was no significant difference between the two groups on effective rate [15.0% vs. 25.0%(P=0.675)]. The deteriorate cases in both groups were zero, and there was no morbidity of complications and death in both groups during the perioperative period. In the 3-month follow up, the reconstruction group had a better marked effect rate [65.0% vs.25.0%(P=0.017)];There was no significant difference between the two groups on the effective rate, no effective rate and total effective rate [20.0% vs.43.8%(P=0.124); 15.0% vs.31.3%(P=0.422); 85.0% vs.68.8%(P=0.422)]. The deteriorate cases and morbidity of complications and death in both groups during the perioperative period were still zero. In the 6- and 12-month follow ups, there were no significant differences between the two groups on marked effect and total effective rate [60.0% vs.37.5%(P=0.180), 80.0% vs.87.5%(P=0.672); 60.0% vs.43.8%(P=0.332), 85.0% vs.87.5% (P=1.000)]. The deteriorate case was zero in both groups, and there was no morbidity of complications and death in both groups. The limb salvage rate in both groups was 100% during the whole follow up period. The reconstruction group had a higher cost[(53 367.4±24 518.3) yuan vs.(30 397.5±15 354.4) yuan(P=0.011)]. There were 8 cases of SFA restenosis/ reocclusion during the follow up,three of which accepted another endovascular treatment, and the reoperation rate was 15.0%. while in the nonreconstruction group, there was no case that needed another endovascular therapy, and the reoperation rate was zero. CONCLUSION: Only dealing with accompanied iliac and profunda artery lesion and neglecting superficial femoral artery reconstruction is a safe, effective and inexpensive therapy for chronic lower extremity arteriosclerosis obliterans, and should be the preferred alternative for some patients.

Clinical and epidemiological assessment concerning hybrid revascularization techniques in the treatment of multilevel arterial occlusive disease.

UNLABELLED: Aim of the study was to report a novel hybrid technique for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the combined (hybrid) treatment, consisting of endovascular intervention and classical surgical intervention on the same vascular axis seems to be the most indicated treatment in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: We have performed a non-randomized study during a 44-month period (January 2010 - September 2013) in a number of 94 patients treated by hybrid revascularization techniques. All the patients included in the study have been post-surgically surveyed at well established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT or MR Angiography. RESULTS: The 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 58.69%, 68.42%, and 62.06%, respectively; the 12 months primary patency was 45.65%, 57.89%, and 34.48%, respectively. Clinical improvement has been noticed in 83 patients (88.29%). There have been registered 19 amputations (20.21% of the cases): 11 majors (thigh and below the knee), representing 11.7% of the total number of cases and 8 minors (toe or transmetatarsal), representing 8.51% of the total number of cases. The amputation-free survival period ranged between 7 days and 24 months, with an average of 7.66 months. CONCLUSIONS: The hybrid techniques are a feasible option for the multilevel arterial disease, with favorable patency and limb salvage rates.

Assessment of multimodality therapy use for extremity sarcoma in the United States.

BACKGROUND: Extremity sarcoma national guidelines offer several stage-specific treatment options; therefore, treatment approaches are not standardized. Our objectives were to examine multimodality treatment trends, practice patterns, and factors associated with neoadjuvant or postoperative adjuvant therapy utilization. METHODS: Using the National Cancer Data Base (2000-2009), treatment of non-metastatic extremity sarcoma was examined. Regression models were developed to identify factors associated with neoadjuvant or postoperative adjuvant therapy receipt and treatment sequence. RESULTS: Twenty-two thousand fifty-one patients underwent resection (stage I: 45.2%, stage II: 27.7%, stage III: 27.1%). Over 10 years, neoadjuvant radiation (6.4-11.6%, P < 0.001) and chemotherapy utilization (1.4-1.8%, P = 0.037) increased, while postoperative radiation (34.3-29.2%, P = 0.023) and trimodality therapy decreased (10.5-9.6%, P = 0.002). After adjusting for age, comorbidities, and histology, patients with large high-grade tumors treated at high-volume academic centers were more likely to receive neoadjuvant therapy (all P < 0.001). Postoperative chemotherapy utilization was associated with younger age, synovial histology, high grade, and surgical margins (all P < 0.001). CONCLUSIONS: Utilization of neoadjuvant therapy for extremity sarcoma has increased over time. Practice patterns are not only related to tumor size, grade, histology, and margins but also hospital type. Opportunities remain to better define the most effective multimodality treatment for extremity sarcoma.

Racial disparities in the use of revascularization before leg amputation in Medicare patients.

OBJECTIVE: Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared with whites. METHODS: Using inpatient Medicare data for the years 2003 through 2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. "Limb salvage care" was defined as limb-related admissions and procedures that occurred during the 2 years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races. RESULTS: Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6% vs 31.6%; P < .0001), any limb-related admission (39.6% vs 44.7%; P < .0001), toe amputation (12.9% vs 13.8%; P < .0005), or wound debridement (11.6% vs 14.2%; P < .0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (odds ratios [OR], 0.72 [95% confidence interval, .68-.76]), limb-related admission (OR, 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR, 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions and were not accounted for by regional differences in where black and white patients received care. CONCLUSION: Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making.

Socioeconomic and hospital-related predictors of amputation for critical limb ischemia.

OBJECTIVE: Disparities in limb salvage procedures may be driven by socioeconomic status (SES) and access to high-volume hospitals. We sought to identify SES factors associated with major amputation in the setting of critical limb ischemia (CLI). METHODS: The 2003-2007 Nationwide Inpatient Sample was queried for discharges containing lower extremity revascularization (LER) or major amputation and chronic CLI (N = 958,120). The Elixhauser method was used to adjust for comorbidities. Significant predictors in bivariate logistic regression were entered into a multivariate logistic regression for the dependent variable of amputation vs LER. RESULTS: Overall, 24.2% of CLI patients underwent amputation. Significant differences were seen between both groups in bivariate and multivariate analysis of SES factors, including race, income, and insurance status. Lower-income patients were more likely to be treated at low-LER-volume institutions (odds ratio [OR], 1.74; P < .001). Patients at higher-LER-volume centers (OR, 15.16; P <.001) admitted electively (OR, 2.19; P < .001) and evaluated with diagnostic imaging (OR, 10.63; P < .001) were more likely to receive LER. CONCLUSIONS: After controlling for comorbidities, minority patients, those with lower SES, and patients with Medicaid were more likely receive amputation for CLI in low-volume hospitals. Addressing SES and hospital factors may reduce amputation rates for CLI.

Finnvasc score and modified Prevent III score predict long-term outcome after infrainguinal surgical and endovascular revascularization for critical limb ischemia.

BACKGROUND: Estimation of the risk of adverse long-term outcome is of paramount importance in the treatment of critical limb ischemia (CLI). METHODS: We evaluated the accuracy of two specific risk score systems, the Finnvasc score and the modified Prevent III (mPIII) score, in 1425 CLI patients who underwent unilateral, infrainguinal surgical (47.6%) or endovascular (52.4%) revascularization. The receiver operating characteristic (ROC) curve analysis was used to estimate the predictive value of these risk scoring methods. RESULTS: The area under the ROC curve of Finnvasc score for prediction of 30-day amputation was 0.609 (95% confidence interval [CI] 0.549-0.677) and of mPIII score 0.533 (95% CI 0.457-0.609). The area under ROC curve of Finnvasc score for prediction of 30-day amputation-free survival was 0.622 (95% CI 0.573-0.671) and of mPIII score 0.588 (95% CI 0.533-0.642). The area under the ROC curve of Finnvasc score for prediction of 1-year amputation-free survival was 0.630 (95% CI 0.597-0.663, P<.0001) and of mPIII score 0.634 (95% CI 0.600-0.667, P<.0001). Finnvasc score predicted leg salvage (relative risk [RR] 1.431, 95% CI 1.319-1.551), survival (RR 1.233, 95% CI 1.116-1.363), and amputation-free survival (RR 1.422, 95% CI 1.319-1.534). mPIII score also predicted leg salvage (RR 1.190, 95% CI 1.108-1.277), survival (RR 1.245, 95% CI 1.193-1.300), and amputation-free survival (RR 1.223, 95% CI 1.176-1.272). CONCLUSIONS: Finnvasc and modified PIII risk scoring methods predict long-term outcome of patients undergoing infrainguinal revascularization for CLI. Finnvasc score seems to perform well also in predicting immediate postoperative outcome.

Knee dislocations with vascular injury: outcomes in the Lower Extremity Assessment Project (LEAP) Study.

OBJECTIVES: The purpose of this study is to report the clinical and functional results of a cohort of patients with knee dislocations associated with vascular injury. METHODS: Patients with knee dislocation and associated vascular injury were prospectively assessed for outcome of severe lower extremity trauma during 2 years. The Sickness Impact Profile was used to assess the functional recovery of the patient. Surgeon and therapist assessments documented clinical metrics and treatment, including salvage or amputation, neurologic recovery, knee stability, and knee motion. RESULTS: Eighteen patients sustained a knee dislocation and an associated popliteal artery injury. Seven patients were found to have an additional vascular injury. All patients underwent repair of the vascular injury. At the time of final follow-up, 14 knees were successfully salvaged and four required amputation (1 below knee amputation, 2 through knee amputation, and 1 above knee amputation). Eighteen patients had at least a popliteal injury and underwent repair of the vascular injury. The patients with a limb-threatening knee dislocation that was successfully reconstructed had Sickness Impact Profile scores of 20.12 at 3 months, 13.18 at 6 months, 12.08 at 1 year, and 7.0 at 2 years after injury. CONCLUSIONS: Patients who sustain a limb-threatening knee dislocation have a moderate to high level of disability 2 years after injury. Nearly one in five patients who present to a Level I trauma center with a dysvascular limb associated with a knee dislocation will require amputation. Prolonged warm ischemia time was associated with a high rate of amputation. Patients who sustain vascular injuries associated with a knee dislocation need immediate transport to a trauma hospital, rapid assessment and diagnosis at presentation, and revascularization. Patients with these injuries can be effectively treated without angiography before surgery.

The complete management of extremity vascular injury in a local population: a wartime report from the 332nd Expeditionary Medical Group/Air Force Theater Hospital, Balad Air Base, Iraq.

BACKGROUND: Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. METHODS: From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. RESULTS: During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n=134), neck and great vessel 17% (n=33), and thoracoabdominal 13% (n=25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n=21). Surgical wound infection occurred in 3.7% (n=5), and acute anastomotic disruption in 3% (n=4). Graft thrombosis occurred in 4.5% (n=6), and early amputation and mortality rates during the study period were 3.0% (n=4) and 1.5% (n=2), respectively. CONCLUSIONS: To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates.

Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies.

PURPOSE: Leg threatening injuries present patients and clinicians with a difficult decision: whether to pursue primary amputation or limb salvage? The purpose of our study was to review the literature in an effort to inform this management decision. METHODS: We systematically searched and selected observational studies that reported on individuals presenting with leg threatening injuries comparing outcomes of limb salvage versus primary amputation. We searched MEDLINE, CINAHL, and EMBASE. We reported on the following outcomes, and pooled data across trials when possible: length of hospital stay, total rehabilitation time, cost, clinical outcomes, failure rate for limb salvage, function & quality of life, pain, return to work, factors associated with poor outcome, and patient preference. RESULTS: Nine observational studies contributed data to our systematic review. The current evidence suggests that while length of hospital stay is similar for limb salvage and primary amputation, length of rehabilitation and total costs are higher for limb salvage patients. Salvage patients requires greater additional surgery and are significantly more likely to undergo re-hospitalization. Long-term functional outcomes (up to 7 years post injury) are equivalent between limb salvage and primary amputation; both forms of management are associated with high rates of self-reported disability (40%; to 50%;), and functional status continues to worsen over time. Report of pain following limb salvage or primary amputation is similar. Return to work is essentially the same between limb salvage and primary amputation groups, with approximately half of such patients returning to competitive employment at 2 years post injury. Both clinical and psychosocial factors are associated with poorer functional outcomes. At the time of injury patients prefer limb salvage, but the majority of failed salvage patients would opt for early amputation if they could decide again. CONCLUSION AND SIGNIFICANCE: Functional outcome among patients who present with leg-threatening injuries are not significantly different, at least up to 7 years, whether they are managed with limb salvage or primary amputation. Research to optimize triage decisions to avoid failed limb salvage as well as on interventions targeting important psychosocial prognostic variables should be considered a priority.

Survival and quality of life after arterial revascularization or major amputation for critical leg ischemia in Guadeloupe.

Functional outcome and survival in 253 patients treated for critical leg ischemia (CLI) in Guadeloupe (French West Indies) were analyzed. Analysis included calculation of quality-of-life score (QLS) from telephone survey data, with a median follow-up time of 42 months (range 12-109). A slight but significant benefit was observed in the 140 patients who underwent arterial reconstruction, with 76% autonomous ambulatory function, 51% independent residential status, and a QLS of 6.9 +/- 1.5 in comparison with the 113 patients who underwent amputation: 34%, 17%, and 5.1 +/- 2, respectively (p < 0.0001). Survival was comparable in the two groups. Inadequate medical follow-up that was either totally lacking or performed only in case of recurrent CLI as well as low rates of rehabilitation (50%) and prosthetic fitting (32%) in the amputation group highlight the existence of a double problem involving therapeutic compliance and vascular follow-up care/rehabilitation in Guadeloupe.

The national hospital discharge register data on lower limb amputations.

AIM: To study if data on lower limb amputations and vascular operations in the National Hospital Discharge Register can be used for comparison of diabetes care between hospital districts. METHODS: We identified diabetic persons from the National Hospital Discharge Register (1988-2002), the National Social Security Institute (since 1964) and pharmacies (since 1994). A search for lower limb amputations and vascular operations was made through the Hospital Discharge Register. An analysis of the correlation of the age and gender adjusted incidence of first major amputations and the age and gender adjusted incidence of first vascular operations for diabetics was made between 14 hospitals districts with the largest diabetic population. RESULTS: A total of 308,447 diabetics were identified. There were 11,070 diabetics who had a lower extremity amputation and 9530 diabetics who had a vascular operation in Finland in 1988-2002. The annual number of first amputations decreased from 924 to 387 per 100,000 diabetics during the study period. There were up to three-fold differences in age and gender adjusted indexed numbers of first amputations between different hospital districts during the last follow-up period from year 2000 to 2002. There was a clear inverse correlation between the incidence of first major amputations and first vascular operations and particularly between incidence of first major amputations and infrapopliteal reconstructions. CONCLUSION: The incidence of major amputation is declining in the diabetic population. This positive development can be explained by more active vascular operative treatment. Regional differences are wider than acceptable.