Major lower extremity amputation: outcome of a modern series

HYPOTHESIS: Major lower extremity amputation results in significant morbidity and mortality. DESIGN: Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months. SETTING: Academic tertiary care center. PATIENTS: Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%). MAIN OUTCOME MEASURES: Patient survival, cardiac morbidity, infectious complications, and subsequent operation. RESULTS: Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001). CONCLUSIONS: Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.     

Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution

Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an average follow-up of 10 +/- 8 months only 65 per cent were alive. Although 51 per cent were discharged to rehabilitation units only 26 per cent regularly wore a prosthesis with 23 per cent ambulating. BKA patients were more likely to ambulate than AKA (34% vs 9%; P = 0.001), and dialysis patients were less likely to ambulate than nondialysis patients (5% vs 25%; P < 0.02). During follow-up 17 per cent of patients discharged with an intact contralateral limb required amputation of that limb and 7 per cent had bypass surgery on that limb. Complication rates were higher in African Americans and Hispanics than in whites (59%, 45%, and 23%, respectively; P < 0.001), although mortality and ambulation rates were similar. Despite an acceptable perioperative mortality complication rates remain high especially in nonwhites. One-year mortality is high. Low rehabilitation rates especially in dialysis patients mandate further efforts in this regard. Vigilant follow-up of the contralateral limb is essential.     

Role of Gritti-Stokes amputation in peripheral vascular disease.

The perigenicula lower limb amputations performed for peripheral vascular disease in Nottingham between April 1987 and September 1992 were reviewed. Of the 434 amputations, 173 were below-knee amputations (BKA), 144 Gritti-Stokes amputations (GSA) and 117 above-knee amputations (AKA). The 30-day mortality was significantly greater for AKA patients than either GSA or BKA patients. There was no difference in mortality within 30 days of amputation between GSA and BKA. Re-amputation rate to a more proximal level was significantly higher in BKA compared with GSA. Mobility after prosthetic rehabilitation was assessed using the Stanmore grading. A greater number of patients achieved mobility grade III and above in the GSA and BKA groups when compared with the AKA group, but there was no significant difference between GSA and BKA groups. At follow-up, a median of 23 months after amputation, there was a tendency for more patients to have given up using their limb prosthesis in the GSA group than either the BKA or AKA groups. However, there remained no significant difference between the BKA and GSA groups in the numbers of patients who remained successfully rehabilitated to Stanmore grade III or above. When a BKA is not possible, GSA offers a better prospect for rehabilitation compared with AKA in patients with occlusive arterial disease.     

Major lower extremity amputations at a Veterans Affairs hospital

BACKGROUND: This study was made to evaluate the experience at a Department of Veterans Affairs (VA) hospital with consecutive major lower extremity amputations over a period of 7 years. METHODS: The records of 229 patients (221 male and 8 female) who underwent 296 consecutive major lower extremity amputations (119 above-knee amputations [AKA] and 177 below-knee amputations [BKA]) over a period of 86 months (September 1994 to October 2001) were retrospectively analyzed. All amputations were performed by members of the vascular surgery department. RESULTS: Forty of the 229 patients (17%) eventually required a contralateral amputation, 27 patients (12%) had BKAs that eventually necessitated conversion to AKA, and 44 amputations (15%) required an initial guillotine amputation. The 30-day mortalities for BKA, AKA, and BKA to AKA operations were 12%, 17%, and 7%, respectively. Eighty-eight of the amputations (30%) developed wound complications, and required 137 revisions. Seventy-seven of the amputations (26%) had undergone prior revascularization, of which 31 (48%) had an early failed bypass. The average preoperative ankle/brachial index (ABI) was 0.57. Of the patients undergoing amputation, 97 (42%) complained of rest pain, 91 (40%) complained of claudication, and 158 (69%) had tissue loss or gangrene at the time of their operation. One hundred and forty-six patients (64%) were diabetic. Twenty-two patients (9%) were dialysis dependent and 81 patients (35%) admitted to smoking. Of the known causes of death, 21 resulted from myocardial infarction, 22 from congestive heart failure, 14 from respiratory failure, 13 from disseminated cancer, 10 from sepsis, 7 from stroke, and 6 from renal failure. Preoperative functional status determinations revealed that of 272 patients with enough information to assess functional status, 43 were totally dependent, 97 were partially independent, and 132 were independent. Of the 229 patients, 168 (73%) were ambulatory prior to their amputation, and at the completion of this review only 53 patients (23%) were ambulatory. CONCLUSIONS: Most patients undergoing major lower extremity amputations have many comorbidities; hence morbidity and mortality rates are high, with the most common causes of death being cardiac and respiratory in nature. These data suggest that major lower extremity amputations highlight a very high-risk population with only 39% survival at 7 years, as well as a costly subset secondary to prolonged hospitalization times (average 15 days, range 3 to 105), in addition to the extraordinary cost associated with diminished functional status.     

Factors Affecting Perioperative Mortality and Wound-Related Complications Following Major Lower Extremity Amputations

Major lower extremity amputations continue to be associated with significant morbidity and mortality, yet few recent large series have evaluated factors associated with perioperative mortality and wound complications. The purpose of this study was to examine factors affecting perioperative mortality and wound-related complications following major lower extremity amputation. A retrospective review was conducted of all adult patients who underwent nontraumatic major lower extremity amputations over a 5-year period at a single tertiary-care center in southern West Virginia. Demographic and clinical data, perioperative data, and outcomes were collected and analyzed to identify any relationship with perioperative mortality, as well as wound complications and early revisions (within 90 days) to a more proximal level. Variables were examined using chi-squared, two-tailed t-tests, and logistic regression. Three hundred eighty patients (61% male) underwent 412 major lower extremity amputations during 1999-2003. The initial level of amputation included 230 below-knee (BKA), 149 above-knee (AKA), and one hip disarticulation. Perioperative mortality was 15.5% (n = 59). From a regression model, age, albumin level, AKA, and lack of a previous coronary artery bypass graft (CABG) were independently related to mortality. Patients who did not have a previous CABG were nearly three times more likely to die than those who did (p = 0.038). Overall early wound complications were noted in 13.4% (n = 51). Four factors were independently related to experiencing a 90-day wound complication: BKA, community (rather than care facility) living, type of anesthesia, and preoperative hematocrit >30%. Major lower extremity amputation in patients with peripheral vascular disease continues to be associated with considerable perioperative morbidity and mortality. Even though the surgical procedure itself may not be challenging from a technical standpoint, underlying medical conditions put this group at high risk for perioperative death. Wound-healing problems are frequently encountered and must be minimized to facilitate early mobilization and hospital discharge.Presented at the 33rd Annual Symposium: Society for Clinical Vascular Surgery, Coral Gables, FL, March 2005.     

Perioperative Use of Dobutamine in Cardiac Surgery and Adverse Cardiac Outcome: Propensity-adjusted Analyses

Background: Catecholamines, mainly dobutamine, are often administered without institutional guidelines or prespecified algorithms in cardiac surgery. The current study assessed the consequences on clinical outcome of catecholamines simply based on the clinical judgment of the anesthesiologists after cardiopulmonary bypass in adult cardiac surgery.

Methods: Consecutive patients were enrolled in a nonrandomized cohort study. Factors associated with perioperative use of catecholamines and with outcomes were recorded prospectively to conduct bias adjustment, including propensity scores. Major cardiac morbidity (i.e., ventricular arrhythmia, use of an intraaortic balloon pump and postoperative myocardial infarction) and all-cause intrahospital mortality were the primary and secondary endpoints, respectively. Results are expressed as odds ratio (OR) [95% confidence interval].

Results: During the study, 84 of 657 patients (13%) received catecholamines, most often dobutamine (76 of 84, 90%). A higher incidence of both major cardiac morbidity (30 vs. 9%; P < 0.001; OR, 4.2 [2.5-7.3]) and all-cause intrahospital mortality (8 vs. 1%; P < 0.001; OR, 12.9 [3.7-45.2]) was observed in the catecholamine group compared with the control group. After adjusting for channeling bias and confounding factors, catecholamine administration remained significantly associated with major cardiac morbidity after propensity score stratification (OR, 2.1 [1.0-4.4]; P < 0.05), propensity score covariance analysis (OR, 2.3 [1.0-5.0]; P < 0.05), marginal structural models (OR, 1.8 [1.3-2.5]; P < 0.001), and propensity score matching (OR, 3.0 [1.2-7.3]; P < 0.02), but not with all-cause intrahospital mortality.     

Major elective surgery for vascular disease in patients aged 80 or more: perioperative (30-day) outcomes

Although major vascular surgery is performed with increasing frequency in elderly people, the impact of age on outcomes is uncertain. We evaluated the perioperative (30-day) outcomes for patients who underwent major elective vascular operations under general or peripheral anesthesia in their eighties and nineties in a 14-year period. Data for all consecutive 3,060 patients (456 of them > or years old) who underwent 3,314 elective vascular surgery procedures were prospectively entered into a computerized vascular registry. Detailed information was collected on patients' preoperative status, type of procedure and anesthesia, perioperative outcomes, and predictors of perioperative outcomes. The end points of the study were perioperative death and main surgical complications. Perioperative all-cause mortality rates varied across operations and were higher in elderly than in younger patients (1.4% vs. 0.2%, P = 0.014) after abdominal surgery (2.4% vs. 0.1%, P = 0.006) and especially after abdominal aortic aneurysm repair (2.8% vs. 0%, P = 0.035). In the elderly cohort, the mortality rate was <1% for almost 60% of all operations. In logistic regression analysis, only preoperative hypertension (odds ratio [OR] = 72.5, 95% confidence interval [CI] 9.4-557.6), congestive heart failure (OR = 16.5, 95% CI 2.3-115.9), and perioperative cardiac (OR = 20.7, 95% CI 1.6-273.8) and pulmonary (OR = 41.7, 95% CI 7.9-218.9) complications were associated with a higher 30-day death risk. In this series, perioperative outcomes were not influenced by the type of elective surgical procedure. Though overall mortality after major vascular surgery was higher in patients > or 80 years old, age per se was not an independent factor of a higher perioperative mortality risk or fatal and nonfatal complications.     

Contemporary Series of Morbidity and Mortality after Lower Limb Amputation

OBJECTIVES: This study was performed in order to assess morbidity and mortality associated with major lower extremity amputation according to an extensive complication registration system used in our hospital. METHODS: All consecutive patients who underwent lower limb major extremity amputation were included from January 1996 until December 2002. Complications were prospectively registered according to our standard complication registration system. RESULTS: In 97 patients 122 amputations were performed including 45 above (AKA) and 77 below (BKA) knee amputations. The conversion rate from below to above knee amputation was 14%. In 65 patients 107 complications occurred (67%). The incidence of wound infection was 10% in the BKA group and 2% in the AKA group. The most frequently reported complications were pressure sores (8%) or originating from the urinary tract (13%). The hospital mortality for BKA was 9% and for AKA 18%. Long-term survival was 62% at 1 year, 50% at 2 years and 29% at 5 years. CONCLUSIONS: An extensive registration system provides us with a detailed insight into the incidence, consequence and cause of complications. Major lower extremity amputations are still associated with considerable morbidity and mortality.     

Type A Aortic Dissection Repair in Patients With Prior Cardiac Surgery

BackgroundEmergency surgery for acute type A aortic dissection in patients with previous cardiac surgery is controversial. This study aimed to evaluate the association between previous cardiac surgery and outcomes after surgery for acute type A aortic dissection, to appreciate whether emergency surgery can be offered with acceptable risks.MethodsAll patients operated on for acute type A aortic dissection between 2005 and 2014 from the Nordic Consortium for Acute Type A Aortic Dissection database were eligible. Patients with previous cardiac surgery were compared with patients without previous cardiac surgery. Univariable and multivariable statistical analyses were performed to identify predictors of 30-day mortality and early major adverse events (a secondary composite endpoint comprising 30-day mortality, perioperative stroke, postoperative cardiac arrest, or de novo dialysis).ResultsIn all, 1159 patients were included, 40 (3.5%) with previous cardiac surgery. Patients with previous cardiac surgery had higher 30-day mortality (30% vs 17.8%, P = .049), worse medium-term survival (51.7% vs 71.2% at 5 years, log rank P = .020), and higher unadjusted prevalence of major adverse events (52.5% vs 35.7%, P = .030). In multivariable analysis, previous cardiac surgery was not associated with 30-day mortality (odds ratio 0.78; 95% CI, 0.30-2.07; P = .624) or major adverse events (odds ratio 1.07; 95% CI, 0.45-2.55, P = .879).ConclusionsMajor adverse events after surgery for acute type A aortic dissection were more frequent in patients with previous cardiac surgery. Previous cardiac surgery itself was not an independent predictor for adverse events, although the small sample size precludes definite conclusions. Previous cardiac surgery should not deter from emergency surgery.     

Risk factors for unplanned readmission and stump complications after major lower extremity amputation

Objective

The unplanned 30-day readmission rate is a marker of quality of patient care across many disciplines. Data regarding risk factors for unplanned readmission after major lower extremity amputation (LEA) are limited. We evaluated predictors of readmission at our institution after major LEA.

Mobility one year after unilateral lower limb amputation: a modern, UK institutional report

The aim of this current retrospective study was to assess postoperative mobility one year after above knee (AKA) or below knee amputation (BKA) in a district general hospital. Data on patient demographics, diabetic status, risks for peripheral vascular disease, mortality and mobility at one year were recorded from the vascular database. Seventy-five patients underwent lower limb amputation over a 70-month period (AKA n=31, BKA n=44). Operative mortality was 10% and mortality at one year 13.7%. Fourteen out of the 31 patients (45.1%) who underwent AKA were mobile independently or with a walking stick compared to 54.5% (24/44) in the BKA group (P=0.44). Fifteen patients (48.3%) were diabetic in the AKA group compared to 26 patients (59.1%) in the BKA group (P=0.49). In the under 60 years group and over 60 years group there was no significant difference in type of amputation (P=0.64) or mobility (P=0.69). In this current series, there was no significant rehabilitation benefits in patients undergoing BKA compared to AKA. With an ageing population who inherently have increasing significant medical problems, the perceived benefit in preserving the knee joint may not be as significant as previously reported.     

Short- and Long-term Prognostic Value of Postoperative Cardiac Troponin I Concentration in Patients Undergoing Coronary Artery Bypass Grafting

Background: The value of postoperative cardiac troponin I (cTnI) has been shown to indicate a higher risk of in-hospital death after cardiac surgery. The authors therefore assessed the long-term prognostic value of cTnI in patients undergoing elective coronary artery bypass grafting.

Methods: Consecutive patients (n = 202) were included and divided into two groups according to the postoperative value of cTnI (< or >= 13 ng/ml). In-hospital mortality and nonfatal cardiac events (delayed extubation > 24 h; postoperative requirement of inotropic agent; ventricular and supraventricular arrhythmia; postoperative myocardial infarction) were recorded. Survivors were then followed up over a 2-yr period. Data are median and odds ratio (95% confidence interval).

Results: Of all patients, 174 (86%) had a low cTnI (4.1 ng/ml; range, 1.1-12.6) and 28 (14%) had a high cTnI (23.8 ng/ml; range, 13.4-174.6). In-hospital mortality was not significantly different (4 vs. 2%), whereas long-term mortality (18 vs. 3%, P = 0.006) and mortality from cardiac cause (18 vs. 1%, P < 0.001) was greater in patients with a high cTnI. A high cTnI was a significant factor predicting death (odds ratio, 7.3 [2.0-27.1]) or death from cardiac causes (odds ratio, 37.4 [4.2-334.4]). Nonfatal cardiac events were also more frequent in the hospital (64 vs. 41%, P = 0.02) and within the 2-yr follow-up period (39%vs. 16%, P = 0.03) in patients with high cTnI.     

Open versus endovascular abdominal aortic aneurysm repair in VA hospitals

BACKGROUND: Endovascular abdominal aortic aneurysm repair (EVAR), when compared with conventional open surgical repair, has been shown to reduce perioperative morbidity and mortality. We performed a retrospective cohort study with prospectively collected data from the Department of Veterans Affairs to examine outcomes after elective aneurysm repair. STUDY DESIGN: We studied 30-day mortality, 1-year survival, and postoperative complications in 1,904 patients who underwent elective abdominal aortic aneurysm repair (EVAR n=717 [37.7%]; open n=1,187 [62.3%]) at 123 Department of Veterans Affairs hospitals between May 1, 2001 and September 30, 2003. We investigated the influence of patient, operative, and hospital variables on outcomes. RESULTS: Patients undergoing EVAR had significantly lower 30-day (3.1% versus 5.6%, p=0.01) and 1- year mortality rates (8.7% versus 12.1%, p=0.018) than patients having open repair. EVAR was associated with a decrease in 30-day postoperative mortality (adjusted odds ratio[OR]=0.59; 95% CI=0.36, 0.99; p=0.04). The risk of perioperative complications was much less after EVAR (15.5% versus 27.7%; p<0.001; unadjusted OR 0.48; 95% CI=0.38, 0.61; p<0.001). Patients operated on at low volume hospitals (25% of entire cohort) were more likely to have had open repair (31.3% compared with 15.9% EVAR; p<0.001) and a nearly two-fold increase in adjusted 30-day mortality risk (OR=1.9; 95% CI=1.19, 2.98; p=0.006). CONCLUSIONS: In routine daily practice, veterans who undergo elective EVAR have substantially lower perioperative mortality and morbidity rates compared with patients having open repair. The benefits of a minimally invasive approach were readily apparent in this cohort, but we recommend using caution in choosing EVAR for all elective abdominal aortic aneurysm repairs until longer-term data on device durability are available.     

Short- and long-term prognostic value of postoperative cardiac troponin I concentration in patients undergoing coronary artery bypass grafting

BACKGROUND: The value of postoperative cardiac troponin I (cTnI) has been shown to indicate a higher risk of in-hospital death after cardiac surgery. The authors therefore assessed the long-term prognostic value of cTnI in patients undergoing elective coronary artery bypass grafting. METHODS: Consecutive patients (n = 202) were included and divided into two groups according to the postoperative value of cTnI (< or >/= 13 ng/ml). In-hospital mortality and nonfatal cardiac events (delayed extubation > 24 h; postoperative requirement of inotropic agent; ventricular and supraventricular arrhythmia; postoperative myocardial infarction) were recorded. Survivors were then followed up over a 2-yr period. Data are median and odds ratio (95% confidence interval). RESULTS: Of all patients, 174 (86%) had a low cTnI (4.1 ng/ml; range, 1.1-12.6) and 28 (14%) had a high cTnI (23.8 ng/ml; range, 13.4-174.6). In-hospital mortality was not significantly different (4 vs. 2%), whereas long-term mortality (18 vs. 3%, P = 0.006) and mortality from cardiac cause (18 vs. 1%, P < 0.001) was greater in patients with a high cTnI. A high cTnI was a significant factor predicting death (odds ratio, 7.3 [2.0-27.1]) or death from cardiac causes (odds ratio, 37.4 [4.2-334.4]). Nonfatal cardiac events were also more frequent in the hospital (64 vs. 41%, P = 0.02) and within the 2-yr follow-up period (39% vs. 16%, P = 0.03) in patients with high cTnI. CONCLUSION: A high postoperative peak of cTnI is associated with increased risk of death, death from cardiac causes, and nonfatal cardiac events within 2 yr after coronary artery bypass grafting.     

Early Extubation following Cardiac Surgery in a Veterans Population

Background: Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population.

Methods: Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups.

Results: One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intra-aortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-[micro sign]g/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-[micro sign]g/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test).     

Major Lower Extremity Amputation in Veterans Affairs Medical Centers

Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.     

Failed femorocrural reconstruction does not prejudice amputation level.

From January 1985 to December 1989, 500 consecutive patients presented to a single vascular unit with limb-threatening acute or critical ischaemia. Vascular reconstruction was attempted unless the patient had insufficient viable tissue to permit weight bearing or complete absence of run-off vessels in the calf. Fifty patients underwent a primary amputation and 450 patients underwent vascular reconstruction, of whom 265 had a femorocrural bypass. Sixty secondary amputations were performed following femorocrural bypass failure. The below-knee amputation to above-knee amputation ratio (BKA:AKA) was 2.0 in the primary amputation group and 1.1 in the secondary amputation group. Direct comparison between the two groups is not valid as they are clinically different. The combined BKA:AKA ratio was 1.4. This compares favourably with the BKA:AKA ratio of recent published series and figures from the National Amputation and Limb Fitting Services. It suggests that an unselective policy of vascular reconstruction for critical ischaemia does not lead to a higher proportion of above-knee amputations.     

Lower extremity amputation: the control series

Although various techniques to determine amputation level have become available, obvious clinical factors may yet identify patients in whom a major amputation is unlikely to heal. We have analyzed the association of multiple clinical factors with the morbidity of 1028 consecutive amputations performed in 786 patients during a 13-year period. The overall operative mortality rate was 7% (57 of 786 patients). Cardiac complications were the leading cause of death (43%). In the 729 patients surviving operation, 345 above-knee amputations (AKAs) and 626 below-knee amputations (BKAs) were performed. After operation, 15.4% of these amputations failed to heal and required proximal revision. The AKA failure rate was 9% and the BKA failure rate was 19%. Significantly higher failure rates were noted in whites, nondiabetics, and those patients with heart disease. It is concluded that major amputation continues to be associated with significant morbidity and mortality rates despite changes in perioperative care and surgical technique. Common clinical characteristics indicate high-risk patients in whom a BKA is unlikely to heal and who may benefit from prospective attempts to determine amputation level.     

Is preoperative balloon aortic valvuloplasty of interest for severe aortic stenosis in hip fracture surgery?

PurposeIn elderly patients, the discovery and management of a severe aortic stenosis (AS) prior to emergency non-cardiac surgery is a frequent and controversial issue. The objective of this study was to evaluate preoperative balloon aortic valvuloplasty (BAV) for severe AS in hip fracture surgery.MethodsWe conducted an observational, monocentric, retrospective study from 2011 to 2018. Survival (30-day, 90-day and 180-day mortality) and the occurrence of perioperative complications were analyzed and compared between control (i.e. no BAV prior to surgery) and preoperative BAV groups in patients with hip fracture surgery and a formal transthoracic echocardiographic diagnosis of severe AS (aortic valve area < 1 cm²). Patients' allocation to the intervention and control groups was after a discussion between cardiologist, anesthesiologist and the surgeon.ResultsAmong the 8506 patients who underwent hip fracture surgery, 29 patients in the control group and 30 patients in the BAV group were finally included. Kaplan-Meier survival analysis demonstrated a significant decrease in mortality in the BAV group (p=0.014) despite an increase in median time to operation of about 48 hours (p<0.0001). Multivariate analysis (stepwise logistic regression) showed that postoperative delirium (OR [95%CI]: 17.5 [1.8-168]; p=0.013) and postoperative acute congestive heart failure (OR [95%CI]: 59.4 [5.0-711.1]; p=0.0013) were predictive factors of 30-day mortality with an area under ROC curve of 0.90 (95%CI: 0.80-0.97; p<0.0001).Conclusionspreoperative BAV for severe AS could reduce the mortality of hip fracture patients despite an increase in time to operation. This improved survival could be linked to the decrease in cardiologic and neurologic adverse events. A larger prospective randomized study is necessary before generalizing our results.     

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome. IMPLICATIONS: Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.