The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study.

OBJECTIVE: To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS: Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS: A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION: The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

Prognostic risk factors for recurrent acute lower limb ischemia in patients treated with intra-arterial thrombolysis.

OBJECTIVE: The objective of this study was to assess factors predisposing patients to recurrent acute lower limb ischemia (RALLI). METHODS: Acute lower limb ischemia patients treated with catheter-directed thrombolysis (CDT) at Tampere University Hospital and Turku University Hospital between March 2002 and December 2015 were included. The patients' baseline demographics, comorbidities, and other characteristics were assessed retrospectively. Significant factors revealed by univariable analysis were tested in a multivariable model for associations with RALLI. A patency analysis was performed, and the risks of reocclusion were identified. The limb salvage rates after reocclusion were evaluated. RESULTS: Altogether, 303 consecutive patients with a mean age of 71 years (standard deviation, 11.8 years) were included. Of them, 159 (52.5%) were men. A total of 164 (54.1%) native arterial and 139 (45.9%) bypass graft occlusions were initially treated with CDT. On completion of CDT, 204 additional endovascular or conventional surgical procedures on 203 patients were performed to obtain adequate distal perfusion. During a median follow-up of 40 months (interquartile range, 69 months), 40 (24.4%) cases of RALLI occurred in native arteries and 90 (64.7%) in bypass graft patients (P < .001). In native arteries, the absence of appropriate anticoagulant and antiplatelet medication was independently associated with the development of acute reocclusions (hazard ratio, 6.51) in the Cox multivariable regression analysis. The patency rates were 86.6%, 72.2%, and 68.0% at 1 year, 5 years, and 9 years, respectively. In bypass grafts, worsened tibial runoff (crural index III: hazard ratio, 2.40) was independently associated with RALLI. The respective patency rates were 60.5%, 34.0%, and 29.2% for synthetic conduits and 30.8%, 20.5%, and 13.7% for autologous vein grafts at 1 year, 5 years, and 9 years. Altogether, 38 (29.2%) major amputations were performed on patients with reocclusions. Patients with synthetic conduits demonstrated superior limb salvage rates after reocclusion in comparison to native arteries or vein grafts (P = .025). CONCLUSIONS: Appropriate post-thrombolytic antiplatelet or anticoagulant treatment after native arterial events is of great importance, but additional data are needed to improve treatment algorithms. Adequate outflow in bypass graft patients is crucial. Patients with prosthetic bypass grafts have superior limb salvage rates after reocclusion.

Survival of Patients and Treatment-Related Outcome After Intra-Arterial Thrombolysis for Acute Lower Limb Ischemia.

BACKGROUND: The aim of this study is to evaluate the long-term survival and treatment-related outcome in patients treated with intra-arterial thrombolysis for acute lower limb ischemia. METHODS: The study was based on a prospective vascular database with retrospectively obtained supplementary information from the patients' files. Additionally, data on the patients' date and cause of death were obtained from Statistics Finland. A total of 155 patients with symptoms or signs of category I-IIa acute lower limb ischemia and angiographic evidence of native artery or bypass graft thromboembolic events were treated with intra-arterial catheter-directed thrombolysis (CDT). Patients with severe ischemic stages at admission or those with contraindications for thrombolysis (n = 185) were treated with conventional surgical modalities and excluded from further analysis. RESULTS: The mean age of the patients at admission was 73 years (95% confidence interval 70.1-74.6). For descriptive purposes, age quartiles were used (≤64, 65-74, 75-82.5, ≥83). The mean follow-up time was 126.3 months. The primary patency rates of native arteries/bypass grafts were 59.8%/31.7%, 35.4%/17.1%, and 18.7%/15.2% at 1, 5, and 10 years, respectively (P = 0.01). Correspondingly, the respective secondary patency rates were 65.2%/55.6%, 46.7%/39.8%, and 22.8%/30.5% (P = 0.88). A total of 190 additional procedures on 122 patients were required to preserve the patency after hospital discharge. At 1 year the cumulative survival was 78%, at 5 years 56%, and at 10 years 29%. The most common cause of death was cardiovascular (68.5%), predominantly presented by an acute coronary syndrome, while 9.6% died of cancer, 6.8% of pulmonary diseases, 8.2% of cerebrovascular causes, and 19.2% owing to trauma and other reasons. Atrial fibrillation (hazards ratio [HR] 2.31) and age over 83 years (HR 5.23 per age category) were significantly and independently associated with poorer cumulative post-procedural survival. Bypass graft thrombosis was associated with an increase in major amputations after CDT (HR 14.77). However, the presence of synthetic bypass grafts had a protective influence on limb salvage (HR 0.086). A total of 39 (25.2%) major amputations were performed during the follow-up period. Age over 75 years was the only significant and independent factor to negatively impact on amputation-free survival (HR 2.01), which was 24% at 10 years. CONCLUSIONS: The long-term patency after CDT is unfavorable, and additional procedures are needed to preserve adequate distal perfusion. Approximately 30% of the patients are alive at 10 years after the initial CDT. Increasing age and atrial fibrillation have a negative effect on the patients' survival.

Therapeutic approach to CLI with tissue loss--a comparative prospective cohort study in Finland and Japan.

BACKGROUND: To compare the demographics, chosen treatment options, and 1-year outcome of patients with severe critical limb ischemia (Fontaine IV) in 2 different patient cohorts. METHODS: A total of 118 consecutive patients with an ischemic tissue lesion in a lower extremity referred for the first time to the vascular surgery outpatient clinic of Helsinki University Hospital and 96 patients referred to the Division of Vascular Surgery of the Tokyo Medical and Dental University Hospital were included in this comparative analysis. Kaplan-Meier estimates were used to assess survival, leg salvage, and amputation-free survival (AFS). Propensity score analysis was used to adjust for differences between the study groups. RESULTS: The median age of the study cohorts was greater in Finland than in Japan (80 vs. 69 years, P < 0.001). The prevalence of coronary artery disease and hypertension were greater in the Finnish cohort (72% vs. 41%, P < 0.001 and 86% vs. 51%, P < 0.001, respectively). The prevalence of male gender (77% vs. 42%, P < 0.001), cerebrovascular disease (35% vs. 20%, P = 0.015), end-stage renal disease (35% vs. 5%, P < 0.001), and current smoking (64% vs. 21%, P < 0.001) was greater in the Japanese cohort. The prevalence of diabetes did not differ between the cohorts (52% vs. 47%, P = 0.286). The proportion of independently ambulant patients at referral was greater in Finland (80% vs. 54%, P < 0.001). In Helsinki and Tokyo, the initial treatment was bypass, an endovascular procedure, conservative treatment, and amputation in 42% vs. 41%, 24% vs. 14%, 24% vs. 41%, and 10% vs. 5% of the cases, respectively. One-year survival, leg salvage, and AFS were 65% vs. 71% (P = 0.326), 82% vs. 74% (P = 0.216), and 59% vs. 55% (P = 0.573) in the Finnish and Japanese cohorts, respectively. AFS was significantly better in ambulant than in nonambulant patients in the combined data (68% vs. 36%, P < 0.001). Adjusted propensity score analysis showed no statistical difference in survival between the study cohorts. CONCLUSIONS: The pattern of comorbid conditions in these 2 patient cohorts is significantly different, but the outcome did not differ significantly between cohorts.

Vein harvesting and techniques for infrainguinal bypass.

In order to achieve good long term results after bypass surgery, alongside with good inflow and outflow arteries, the bypass graft material also has an important role. The best patency and limb salvage rates are achieved with autologous vein. If great saphenous vein is not available, acceptable long-term results can be achieved with arm veins and lesser saphenous vein. The quality and size of the vein are important. A small-caliber vein, increased wall thickness, postphlebitic changes and varicosities are associated with a risk of early failure. Preoperative vein mapping with ultrasound reduces readmissions and postoperative surgical site infections. During the mapping, the vein to be used and its main tributaries are marked with a permanent marker pen. To reduce wound complication rates we recommend bridged incisions in vein harvesting. Endoscopic vein harvesting seems to have no benefit compared to open techniques in lower limb bypasses, and has been associated with higher risk of primary patency loss at one year. With deep tunneling of the graft the problems caused by wound infection can be avoided.