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Limb Salvage vs Amputation for Critical Ischemia: The Role of Vascular Surgery

Limb Salvage vs Amputation for Critical Ischemia: The Role of Vascular Surgery Abstract • Since 1980,498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index <0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure. (Arch Surg. 1991;126:1251-1258) References 1. Veith FJ, Gupta SK, Samson RH, et al. Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures . Ann Surg . 1981;194:386-401.Crossref 2. Brown OW, Dosick SM, Whalen RC, Blakemore WS. Distal bypass graft for limb salvage . J Cardiovasc Surg . 1982;23:314-317. 3. Auer AI, Hurley JJ, Binnington HB, Nunnelee JD, Hershey FB. Distal tibial vein grafts for limb salvage . Arch Surg . 1983;118:597-602.Crossref 4. Naji A, Chu J, McCombs PR, Barker CF, Berkowitz HD, Roberts B. Results of 100 consecutive femoropopliteal vein grafts for limb salvage . Ann Surg . 1978;188:162-165.Crossref 5. Leather RP, Shah DM, Karmody AM. Infrapopliteal arterial bypass for limb salvage: increased patency and utilization of the saphenous vein used 'in situ.' Surgery . 1981;90:1000-1008. 6. Veith FJ, Gupta SK, Wengerter KR, et al. Changing arteriosclerotic disease patterns and management strategies in lower limb-threatening ischemia . Ann Surg . 1990;212:402-414.Crossref 7. Taylor LM Jr, Edwards JM, Porter JM. Present status of reversed vein bypass grafting: five-year results of a modern series . J Vasc Surg . 1990;11:193-206.Crossref 8. Leather RP, Shah DM, Chang BB, Kaufman JL. Resurrection of the in situ saphenous vein bypass . Ann Surg . 1988;208:435-442.Crossref 9. Ascer E, Veith FJ, Gupta SK, et al. Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage . J Cardiovasc Surg . 1985;26:468-472. 10. Reichle FA, Rankin KP, Tyson RR, Firestone AJ, Sherman C. Long-term results of femoroinfrapopliteal bypass in diabetic patients with severe ischemia of the lower extremity . Am J Surg . 1979;137:653-659.Crossref 11. Taylor LM Jr, Edwards JM, Phinney ES, Porter JM. Autogenous reversed vein bypass for lower extremity ischemia in patients with absent or inadequate greater saphenous vein . Am J Surg . 1987;153:505-510.Crossref 12. Harris RW, Andros G, Dulawa LB, Oblath RW, Salles-Cunha SX, Apyan R. Successful long-term limb salvage using cephalic vein bypass grafts . Ann Surg . 1984;200:785-792.Crossref 13. Dennis JW, Littooy FN, Greisler HP, Baker WH. Secondary vascular procedures with polytetrafluoroethylene for lower extremity ischemia in a male veteran population . J Vasc Surg . 1988;8:137-142.Crossref 14. Verta MJ. Pedal artery bypass for limb salvage . Surg Gynecol Obstet . 1982;155:401-405. 15. Ascer E, Veith FJ, Gupta SK. Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage . J Vasc Surg . 1988;8:434-441.Crossref 16. Cronenwett JL, McDaniel MD, Zwolak RM, et al. Limb salvage despite extensive tissue loss . Arch Surg . 1989;124:609-615.Crossref 17. Couch NP. Natural history of the leg amputee . Am J Surg . 1977;133:469-473.Crossref 18. Rush DS. Operative and late mortality rates of above-knee and below-knee amputations . Am Surg . 1981;47:36-39. 19. Jamieson CW, Hill D. Amputation for vascular disease . Br J Surg . 1976;63:683-690.Crossref 20. Andros G, Harris RW, Dulawa LB, Oblath RW, Cunha SX. The need for arteriography in diabetic patients with gangrene and palpable foot pulses . Arch Surg . 1984;119:1260-1263.Crossref 21. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Standards for reports dealing with lower extremity ischemia . J Vasc Surg . 1986;4:80-94.Crossref 22. Baur GM, Zupan TL, Holmgren-Gates K, Porter JM. Blood flow in the common femoral artery . Am J Surg . 1983;145:585-588.Crossref 23. Kozak BE, Bedell JE, Rosch J. Small vessel leg angiography for distal vessel bypass grafts . J Vasc Surg . 1988;8:711-715.Crossref 24. Phinney ES, Edwards JM, Herring MB, Taylor LM Jr, Porter JM. Vascular lab prediction of pedal pressure following femoropopliteal bypass . Ann Vasc Surg . 1988;2:1-5.Crossref 25. Dalman RL, Taylor LM Jr, Moneta GL, Yeager RA, Porter JM. Simultaneous operative repair of multilevel lower extremity occlusive disease . J Vasc Surg . 1991;13:211-221.Crossref 26. Taylor LM Jr, Porter JM. Technique of reversed vein bypass to distal leg arteries . In: Bergan JJ, Yao JST, eds. Techniques in Arterial Surgery . Philadelphia, Pa: WB Saunders Co; 1990:109-122. 27. Bandyk DF, Cato RF, Towne JB. A low flow velocity predicts failure of femoro-popliteal and femoro-tibial bypass grafts . Surgery . 1985;98:799-809. 28. Le MC, Luscombe JA, Figg-Hoblyn L, Taylor LM Jr, Porter JM. Decreased graft flow velocity is a reliable early indication of impending failure of reversed vein grafts . J Vasc Technol . 1988;12:133-137. 29. Rivers SP, Veith FJ, Ascer E, et al. Successful conservative therapy of severe limb threatening ischemia: the value of nonsympathectomy . Surgery . 1986;99:759. 30. Eklund AE, Eriksson G, Olsson AG. A controlled study showing significant short term effect of prostaglandin E1 in healing of ischemic ulcers of the lower limb in man . Prostaglandins Leukotrienes Med . 1982;8:265.Crossref 31. Schuler JJ, Flanigan DP, Holcroft JW, et al. Efficacy of prostaglandin E1 in the treatment of ischemic ulcers secondary to peripheral vascular occlusive disease: results of a prospective randomized, double-blind, multicenter clinical trial . J Vasc Surg . 1984;1:160. 32. Stoney R. Ultimate salvage for the patient with limbthreatening ischemia: realistic goals and surgical considerations . Am J Surg . 1978;136:228-232.Crossref 33. Malone JM, Moore WS, Goldstone J, Malone SJ. Therapeutic and economic impact of a modern amputation program . Ann Surg . 1979;189:798-802.Crossref 34. DeFrang RD, Taylor LM Jr, Porter JM. Basic data regarding lower extremity amputation for ischemia . Ann Vasc Surg . 1991;5:202-207.Crossref 35. High RM, McDowell DE, Savrin RA. A critical review of amputation in vascular patients . J Vasc Surg . 1984;1:653-655.Crossref 36. Porter JM, Baur GM, Taylor LM Jr. Lower extremity amputations for ischemia . Arch Surg . 1981;116:89-92.Crossref 37. Ouriel K, Fiore WM, Geary JE. Limb-threatening ischemia in the medically compromised patient: amputation or revascularization . Surgery . 1988;104:667-672. 38. Kazmers M, Satiani B, Evans WE. Amputation level following unsuccessful distal limb salvage operations . Surgery . 1980;87:683-687. 39. Samson RH, Gupta SK, Scher LA, Veith FJ. Level of amputation after failure of limb salvage procedures . Surg Gynecol Obstet . 1982;154:56-58. 40. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD) . Arch Surg . 1988;123:1164-1168.Crossref 41. Harrington EB, Harrington ME, Schanzer H, Haimov M. End-stage renal disease: is infrainguinal limb revascularization justified? J Vasc Surg . 1990;12:691-696.Crossref 42. Raviola CA, Nichter LS, Baker DJ, Busuttil RW, Machleder HI, Moore WS. Cost of treating advanced leg ischemia: bypass graft vs primary amputation . Arch Surg . 1988;123:495-496.Crossref 43. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia . Surgery . 1986;99:26-34. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Surgery American Medical Association

Limb Salvage vs Amputation for Critical Ischemia: The Role of Vascular Surgery

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Publisher
American Medical Association
Copyright
Copyright © 1991 American Medical Association. All Rights Reserved.
ISSN
0004-0010
eISSN
1538-3644
DOI
10.1001/archsurg.1991.01410340093013
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Abstract

Abstract • Since 1980,498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index <0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure. (Arch Surg. 1991;126:1251-1258) References 1. Veith FJ, Gupta SK, Samson RH, et al. Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures . Ann Surg . 1981;194:386-401.Crossref 2. Brown OW, Dosick SM, Whalen RC, Blakemore WS. Distal bypass graft for limb salvage . J Cardiovasc Surg . 1982;23:314-317. 3. Auer AI, Hurley JJ, Binnington HB, Nunnelee JD, Hershey FB. Distal tibial vein grafts for limb salvage . Arch Surg . 1983;118:597-602.Crossref 4. Naji A, Chu J, McCombs PR, Barker CF, Berkowitz HD, Roberts B. Results of 100 consecutive femoropopliteal vein grafts for limb salvage . Ann Surg . 1978;188:162-165.Crossref 5. Leather RP, Shah DM, Karmody AM. Infrapopliteal arterial bypass for limb salvage: increased patency and utilization of the saphenous vein used 'in situ.' Surgery . 1981;90:1000-1008. 6. Veith FJ, Gupta SK, Wengerter KR, et al. Changing arteriosclerotic disease patterns and management strategies in lower limb-threatening ischemia . Ann Surg . 1990;212:402-414.Crossref 7. Taylor LM Jr, Edwards JM, Porter JM. Present status of reversed vein bypass grafting: five-year results of a modern series . J Vasc Surg . 1990;11:193-206.Crossref 8. Leather RP, Shah DM, Chang BB, Kaufman JL. Resurrection of the in situ saphenous vein bypass . Ann Surg . 1988;208:435-442.Crossref 9. Ascer E, Veith FJ, Gupta SK, et al. Six year experience with expanded polytetrafluoroethylene arterial grafts for limb salvage . J Cardiovasc Surg . 1985;26:468-472. 10. Reichle FA, Rankin KP, Tyson RR, Firestone AJ, Sherman C. Long-term results of femoroinfrapopliteal bypass in diabetic patients with severe ischemia of the lower extremity . Am J Surg . 1979;137:653-659.Crossref 11. Taylor LM Jr, Edwards JM, Phinney ES, Porter JM. Autogenous reversed vein bypass for lower extremity ischemia in patients with absent or inadequate greater saphenous vein . Am J Surg . 1987;153:505-510.Crossref 12. Harris RW, Andros G, Dulawa LB, Oblath RW, Salles-Cunha SX, Apyan R. Successful long-term limb salvage using cephalic vein bypass grafts . Ann Surg . 1984;200:785-792.Crossref 13. Dennis JW, Littooy FN, Greisler HP, Baker WH. Secondary vascular procedures with polytetrafluoroethylene for lower extremity ischemia in a male veteran population . J Vasc Surg . 1988;8:137-142.Crossref 14. Verta MJ. Pedal artery bypass for limb salvage . Surg Gynecol Obstet . 1982;155:401-405. 15. Ascer E, Veith FJ, Gupta SK. Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage . J Vasc Surg . 1988;8:434-441.Crossref 16. Cronenwett JL, McDaniel MD, Zwolak RM, et al. Limb salvage despite extensive tissue loss . Arch Surg . 1989;124:609-615.Crossref 17. Couch NP. Natural history of the leg amputee . Am J Surg . 1977;133:469-473.Crossref 18. Rush DS. Operative and late mortality rates of above-knee and below-knee amputations . Am Surg . 1981;47:36-39. 19. Jamieson CW, Hill D. Amputation for vascular disease . Br J Surg . 1976;63:683-690.Crossref 20. Andros G, Harris RW, Dulawa LB, Oblath RW, Cunha SX. The need for arteriography in diabetic patients with gangrene and palpable foot pulses . Arch Surg . 1984;119:1260-1263.Crossref 21. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Standards for reports dealing with lower extremity ischemia . J Vasc Surg . 1986;4:80-94.Crossref 22. Baur GM, Zupan TL, Holmgren-Gates K, Porter JM. Blood flow in the common femoral artery . Am J Surg . 1983;145:585-588.Crossref 23. Kozak BE, Bedell JE, Rosch J. Small vessel leg angiography for distal vessel bypass grafts . J Vasc Surg . 1988;8:711-715.Crossref 24. Phinney ES, Edwards JM, Herring MB, Taylor LM Jr, Porter JM. Vascular lab prediction of pedal pressure following femoropopliteal bypass . Ann Vasc Surg . 1988;2:1-5.Crossref 25. Dalman RL, Taylor LM Jr, Moneta GL, Yeager RA, Porter JM. Simultaneous operative repair of multilevel lower extremity occlusive disease . J Vasc Surg . 1991;13:211-221.Crossref 26. Taylor LM Jr, Porter JM. Technique of reversed vein bypass to distal leg arteries . In: Bergan JJ, Yao JST, eds. Techniques in Arterial Surgery . Philadelphia, Pa: WB Saunders Co; 1990:109-122. 27. Bandyk DF, Cato RF, Towne JB. A low flow velocity predicts failure of femoro-popliteal and femoro-tibial bypass grafts . Surgery . 1985;98:799-809. 28. Le MC, Luscombe JA, Figg-Hoblyn L, Taylor LM Jr, Porter JM. Decreased graft flow velocity is a reliable early indication of impending failure of reversed vein grafts . J Vasc Technol . 1988;12:133-137. 29. Rivers SP, Veith FJ, Ascer E, et al. Successful conservative therapy of severe limb threatening ischemia: the value of nonsympathectomy . Surgery . 1986;99:759. 30. Eklund AE, Eriksson G, Olsson AG. A controlled study showing significant short term effect of prostaglandin E1 in healing of ischemic ulcers of the lower limb in man . Prostaglandins Leukotrienes Med . 1982;8:265.Crossref 31. Schuler JJ, Flanigan DP, Holcroft JW, et al. Efficacy of prostaglandin E1 in the treatment of ischemic ulcers secondary to peripheral vascular occlusive disease: results of a prospective randomized, double-blind, multicenter clinical trial . J Vasc Surg . 1984;1:160. 32. Stoney R. Ultimate salvage for the patient with limbthreatening ischemia: realistic goals and surgical considerations . Am J Surg . 1978;136:228-232.Crossref 33. Malone JM, Moore WS, Goldstone J, Malone SJ. Therapeutic and economic impact of a modern amputation program . Ann Surg . 1979;189:798-802.Crossref 34. DeFrang RD, Taylor LM Jr, Porter JM. Basic data regarding lower extremity amputation for ischemia . Ann Vasc Surg . 1991;5:202-207.Crossref 35. High RM, McDowell DE, Savrin RA. A critical review of amputation in vascular patients . J Vasc Surg . 1984;1:653-655.Crossref 36. Porter JM, Baur GM, Taylor LM Jr. Lower extremity amputations for ischemia . Arch Surg . 1981;116:89-92.Crossref 37. Ouriel K, Fiore WM, Geary JE. Limb-threatening ischemia in the medically compromised patient: amputation or revascularization . Surgery . 1988;104:667-672. 38. Kazmers M, Satiani B, Evans WE. Amputation level following unsuccessful distal limb salvage operations . Surgery . 1980;87:683-687. 39. Samson RH, Gupta SK, Scher LA, Veith FJ. Level of amputation after failure of limb salvage procedures . Surg Gynecol Obstet . 1982;154:56-58. 40. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD) . Arch Surg . 1988;123:1164-1168.Crossref 41. Harrington EB, Harrington ME, Schanzer H, Haimov M. End-stage renal disease: is infrainguinal limb revascularization justified? J Vasc Surg . 1990;12:691-696.Crossref 42. Raviola CA, Nichter LS, Baker DJ, Busuttil RW, Machleder HI, Moore WS. Cost of treating advanced leg ischemia: bypass graft vs primary amputation . Arch Surg . 1988;123:495-496.Crossref 43. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia . Surgery . 1986;99:26-34.

Journal

Archives of Surgery – American Medical Association

Published: Oct 1, 1991

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