Independent Risk Factors For Amputation Research Articles

Impact of Plaque Calcification and Stent Oversizing on Clinical Outcomes of Atherosclerotic Femoropopliteal Arterial Occlusive Disease Following Stent Angioplasty

Plaque calcification and stent oversizing are two key factors contributing to in stent restenosis (ISR) following femoropopliteal stent angioplasty. This study aimed to explore a pre-operative quantitative assessment method of plaque calcification and rational parameters of stent oversizing in the femoropopliteal artery. A total of 115 patients with atherosclerotic femoropopliteal arterial occlusive disease treated from January 2013 to January 2016 were included retrospectively. Computed tomography angiography (CTA) imaging was performed to analyse calcified plaque parameters (calcified plaque volume [CV], standard CV [SCV], burden of calcified plaque) and stent oversizing parameters at different vessel segments (distal oversizing, maximum oversizing, plaque oversizing). Optimal cut offs for the six parameters were determined by the maximum Youden's index. The relationship between calcified plaque, stent oversizing, and clinical outcomes were assessed by correlation analysis and multivariable Cox regression models. The one year primary patency rate was 77.4%; the rates of ISR, major amputation, target lesion revascularisation, and mortality were 40.9%, 8.7%, 17.4%, and 12.2%, respectively. For all six parameters, patients with values greater than the cut offs had a significantly higher incidence of ISR than those with values below the cut offs. ISR was positively correlated with all six calcification and oversizing parameters. Amputation and mortality were positively correlated with calcification parameters. Multivariable Cox regression analysis demonstrated that all six parameters were independent risk factors for ISR. All calcification parameters were identified as independent risk factors for amputation, while only CV and SCV were independent risk factors for mortality. Calcified plaque in the femoropopliteal artery can be quantitatively analysed on pre-operative CTA images. High calcified plaque burden and excessive stent oversizing were associated with unfavourable outcomes following stent angioplasty.

357 Neuropathy may be an Independent Risk Factor for Amputation Following Lower Extremity Burn in Diabetic Adults

357 Neuropathy may be an Independent Risk Factor for Amputation Following Lower Extremity Burn in Diabetic Adults

Risk factors for amputation in patients with diabetic foot infection: a prospective study.

There is a variety of diagnostic and therapeutic algorithms for diabetic foot infections (DFIs). Some of them are too difficult to be applied in routine clinical approach. In the routine clinical approach, it is necessary to find new risk factors and end up with a quick and easy assessment of DFIs. In this study, we aimed to evaluate the independent risk factors for osteomyelitis, amputation and major amputation in patients with DFI using standard scoring procedures. We prospectively studied 379 patients with DFI. The variables were analysed using logistic analysis. A total of 126 cases (33·2%) underwent amputation. The odds ratios in the amputation model were 3·09 for osteomyelitis (P < 0·001), 4·90 for arterial stenosis (AS) (P < 0·001), 3·67 for the history of DFI (P = 0·001), 2·47 for ulcer duration >60 days (P = 0·001), 3·10 for ulcer depth > 15 mm (P < 0·001) and 10·28 for fungal DFI (P = 0·015). In this study, the unusual result of well-known literature was fungal DFI as an independent risk factor for amputation in patients with DFI.

Abstract No. 401 - Outcomes of endovascular intervention on atherosclerotic disease involving the popliteal artery

To evaluate outcomes including limb salvage, amputation-free survival, and patency after endovascular intervention in patients with atherosclerotic popliteal artery disease. We retrospectively reviewed all cases with endovascular intervention on the popliteal artery in patients with atherosclerotic arterial disease between 7/2005 and 8/2015. A total of 207 limbs were treated in 206 patients (median age 70.0 years, range 46-94, 121 males and 85 females) with Rutherford classification of 3-5. The popliteal artery lesions were treated with primary angioplasty and secondary stent implantation for suboptimal angioplasty results. Kaplan-Meier analyses were performed to estimate the cumulative distribution functions for limb salvage, amputation-free survival, primary patency and primary assisted patency. Univariate and multivariate analysis with COX model were performed to obtain hazard ratio (HR) estimates. Limb salvage rates were 87.6%, 84.1%, and 79.4% at 12, 24, and 48 months, respectively; Amputation-free survival rates were 71.6%, 66.9%, and 49.2% at 12, 24, and 48 months, respectively; Primary patency was 55.1%, 46.3%, and 38.4% at 12, 24, and 48 months, respectively, with median primary patency of 17.2 months; primary assisted patency was 70.1%, 60.5%, and 48.2% at 12, 24, and 48 months, respectively, with median primary assisted patency of 48.8 months. Diabetes was an independent risk factor for limb amputation (HR = 2.62; 95% CI: [0.99, 6.97], P = 0.053); chronic kidney disease was an independent risk factor for amputation or death (HR = 1.84; [1.17, 2.89], P = 0.008); and smaller artery size was an independent risk factor associated with decreased patency (HR = 0.74; [0.57, 0.97], P = 0.029). Run-off weighting, presence of chronic occlusion, and stent use were not predictors of poor outcome for vessel patency. Endovascular intervention on atherosclerotic lesions in the popliteal artery provided modest patency outcomes. Diabetes and chronic kidney disease were predictors of poor outcomes for limb salvage and amputation-free survival, respectively, while smaller artery size was a predictor for poor vessel patency.

Results of Infrainguinal Bypass in Acute Limb Ischaemia

To assess the outcomes of infrainguinal bypass performed for acute limb ischaemia, as well as the predictors of patency, mortality, and amputation. This was a retrospective cohort study of patients undergoing infrainguinal bypass between 1998 and 2014. The cohort was stratified according to the indication for surgery into two groups: group A (acute limb ischaemia) and group B (chronic lower extremity ischaemia). Comparative analysis was performed on comorbidities, surgical technique, and outcomes, as well as prognostic factors in group A. In total, 702 bypasses were performed (group A, n=107; group B, n=595). Differences between groups were detected in age (65.9 vs. 70.9 years; p=.03), diabetes (16% vs. 49%; p<.01), renal insufficiency (6% vs. 13%; p=.05), stroke (7% vs. 14%; p=.04), and coronary artery disease (13% vs. 28%; p<.01). Patients with acute limb ischaemia more often required general anaesthesia (47% vs. 12%; p<.01) and a short bypass was more often performed (32% vs. 7%; p<.01). Median follow up was 23 and 24 months for groups A and B, respectively. No differences were found in patency rates at 1, 12, and 24 months between groups, but group B had a higher re-intervention rate during follow up. Primary patency in group A was 84%, 63%, and 58%, and in group B it was 88%, 62%, and 53% at 1, 12, and 24 months, respectively (p=.77). Assisted primary patency in group A was 85%, 72%, and 67%, and in group B it was 90%, 74%, and 66% at 1, 12, and 24 months, respectively (p=.61). Secondary patency in group A was 90%, 78%, and 75%, and in group B it was 94%, 80%, and 74% at 1, 12, and 24 months, respectively (p=.80). The freedom from re-intervention rate in group A was 91%, 74%, and 68%, and in group B it was 92%, 76%, and 71%, respectively (p=.04). Acute limb ischaemia was an independent risk factor for amputation (odds ratio [OR] 4.96, 95% confidence interval [CI] 1.74-14.09; p<.01) and mortality (OR 4.13, 95% CI 1.53-11.14; p=.01) at 30 days. In group A, female sex, prosthetic conduit, and need of distal thrombectomy were independently associated with worse patency rates. Poor intra-operative runoff was correlated with higher amputation rates. Among those undergoing infrainguinal bypass, patients who present with acute limb ischaemia constitute a subset showing higher early rates of amputation and death. In this subset of patients, worse outcomes may be expected for women, prosthetic conduits, need for distal thrombectomy, and patients with poor intra-operative runoff.

Epidemiology and outcomes of 655 diabetic foot patients in a Brazilian university hospital

Results Sixty seven percent (442) were males; the age ranged from 21 to 102 years (median 63 years). Arterial ischemia was present in 28% of the patients. Among these diabetic patients 73% had hypertension and 30% were active smokers. The in-hospital mortality rate was 12%, and there was no statistically difference between patients with ischemic and non-ischemic lesions (P=0.16). Of the 576 patients alive, 61% were not readmitted, 21% were readmitted once and 18% were readmitted twice or more times. The minor amputation rate was 48% while major amputations were performed in 21% of the subjects (28% below the knee amputation and 72% above the knee amputation). The major amputation free survival rate was 72%. After discharge 47% of the patients required special home-care for dressings and for parenteral drug administration. Independent risk factor for amputation were age (OR: 1.02; 95%CI: 1.0011.035; P=0.041) and arterial ischemia (OR 2.20; 95%CI 1.46-3.31; P<0.0001). Independent risk factors for death were age (OR 1.06; 95% CI 1.03 – 1.08; P<0.01) and major amputations (OR 2.38; 95% CI 1.41 – 3.99; P=0.01).

Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer.

Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation. We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively). For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.

Usefulness of Neutrophil/Lymphocyte Ratio as a Predictor of Amputation after Embolectomy for Acute Limb Ischemia

The aim of this study was to examine the predictive ability of admission neutrophil/lymphocyte ratio (NLR) for predicting amputation in patients with acute limb ischemia who underwent embolectomy. We retrospectively analyzed the clinical, hematologic, and amputation data of 254 patients who had undergone embolectomy for acute limb ischemia. There were 152 (52%) men and 93 (48%) women, with a mean age of 66.04 ± 13.30 years. The admission NLR was determined by dividing the absolute neutrophil count by the absolute lymphocyte count. The primary end point was determined as amputation and death. The mean duration of follow-up was 26 months. During the follow-up period, there were 18 (7%) amputations within 30 days of surgery and 36 (15%) amputations over a mean follow-up of 26 months. Based on multivariate logistic regression modeling, no arterial back bleeding and preoperative NLR were observed to be independent risk factors for amputation within 30 days of surgery, and no arterial back bleeding and preoperative NLR were observed to be independent risk factors for midterm amputation for the same time period. A NLR of ≥5.2 was taken as the cutoff based upon the receiver operating characteristic. In receiver operating characteristic curve analysis, a NLR ≥5.2 had 83% sensitivity and 63% specificity in predicting amputation within 30 days of surgery and 63% sensitivity and 63% specificity in predicting midterm amputation. An elevated NLR is associated with a poorer limb survival after embolectomy. This simple, inexpensive test may therefore be added to risk stratification of these high-risk patients.

Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital (在公立、私立以及退伍军人管理局医院中的糖尿病足溃疡的最初表现与治疗结果的差异)

Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes. A retrospective chart review of diabetic patients with a new diagnosis of a foot ulcer at geographically adjacent, but independent public, private, and Veterans Administration (VA) hospitals was conducted. Healing and lower extremity amputation outcomes were assessed. Across the three hospitals, 234 patients met the inclusion criteria. Patients at the VA hospital were older (mean 72.5 years; P < 0.001) and had gangrenous ulcers (mean 14.1%; P < 0.001) compared with patients in the private and public hospitals. Public hospital patients were mostly Hispanic (mean 54%; P < 0.001) with a shorter duration of diabetes (mean 12.8 years; P = 0.02), but were more poorly controlled than VA and private hospital patients (P ≤ 0.001). Prior amputation (odds ratio [OR] 1.97; P = 0.016) and non-Caucasian race (OR 2.42; P = 0.004) increased the risk of amputation on multivariate analysis. Osteomyelitis (P = 0.0371) and gangrene (P < 0.001) are independent risk factors for amputation. Across all three hospitals, 42.3% of patients were treated by amputation (6.8% private, 12% public and 23.5% VA; P < 0.001). In a single triumvirate health care system where the patient population is stratified primarily by insurance, VA patients have significantly higher amputation rates compared with patients at adjacent private and public hospitals. The VA patients are largely racial minorities with advanced DFU progression to gangrenous ulcers.

Gender Differences in Outcome after Stent Treatment of Lesions in the Femoropopliteal Segment

Although endovascular stent treatment is increasingly used in infrainguinal atherosclerotic occlusive disease, outcome with focus on gender differences has not been reported in detail. One hundred and twelve consecutive patients (67 [60%]) women, undergoing endovascular nitinol stent treatment of atherosclerotic lesions in the femoropopliteal segment were analysed concerning improvement in ankle brachial index (ABI), reinterventions, complications, amputation and survival rates up to 12 months after intervention. Risk factors for amputation and death were analyzed with logistic regression. At presentation, women showed critical limb ischemia (CLI) more often than men (87% vs. 58 %; P = 0.001). After 12 months ABI had improved (from 0.40 ± 0.26 at baseline to 0.86 ± 0.22 after 12 months, P < 0.001), but 16 patients (15%) had been amputated and 27 patients (24 %) had died. After adjustment for age, diabetes mellitus and smoking, female gender was an independent risk factor for amputation (OR 9.0; 95% CI 1.1-76.5; P = 0.045). Stent treatment of lesions in the femoropopliteal segment had favourable effects on ABI and limb salvage. Treated women more often had CLI and ran a higher risk for amputation within 12 months than men. This might reflect failure of clinicians to adequately appreciate symptoms of atherosclerotic leg artery disease in women.

A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease

In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980-June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70.5-85.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.

Independent risk factors for amputation in diabetic foot

BACKGROUND:Diabetic foot (DF) is the main cause of nontraumatic lower extremity amputation. Early recognition and management of risk factors for foot complications may prevent amputations and other adverse outcomes.MATERIALS AND METHODS:At our hospital we have a protocol for the management of patients hospitalized because of DF. We collected clinical and laboratory data, details of diabetes complications, and history of comorbidities in 146 patients who were admitted for management of DF to determine the risk factors of amputation (major or minor) in these patients. We divided these patients into two groups, those whose treatment included amputation and those who were treated conservatively and carried out a comparative analysis of the variables in the two groups.RESULTS:Major amputation was performed in 5.5% of the patients and minor amputation in 22.6%. Those who required amputation presented a significantly higher (P < 0.05) incidence of nephropathy, history of previous amputation, ischemic diabetic foot and first fasting blood glucose (FBG) > 200 mg/dl after admission. Multivariable-adjusted odds ratios in stepwise logistic regression model was 2.64 for nephropathy (95%CI: 1.06 to 6.60; P = 0.03); 3.03 for ischemic diabetic foot (95%CI: 1.28 to 7.18; P = 0.01); and 3.01 for first FBG > 200 after admission (95%CI: 1.32 to 6.83; P= 0.01).CONCLUSION:Nephropathy, ischemic diabetic foot, and first FBG > 200 mg/dl are independent predictors of limb amputation in patients hospitalized for DF lesions. In addition to early detection and treatment of foot lesions, early management of risk factors is also important.

Changes in the management of critical limb ischaemia.

A prospective study of all patients with critical limb ischaemia (CLI) who presented to a single vascular unit was undertaken for a 12-month period. There were 222 referrals in 188 patients, 80.2 per cent of which were emergency or urgent admissions. The majority (72.5 per cent) were initially investigated with colour duplex scanning to characterize the arterial lesion. Diagnostic angiography was performed in 35.1 per cent. An attempt at revascularization was made in 73.0 per cent of cases using percutaneous transluminal angioplasty (PTA) in 42.3 per cent, surgery in 24.3 per cent, and a combination of surgery and PTA in 6.3 per cent. Primary major amputation was required in 22 cases (9.9 per cent) and conservative treatments were used in 38 (17.1 per cent). The in-hospital mortality rate was 10 per cent with a limb salvage rate of 79 per cent. Diabetes was an independent risk factor for amputation (odds ratio 2.4, 95 per cent confidence interval 1.22-4.79, P = 0.012). Median hospital stay was much shorter for patients treated by PTA (4.5 days) than surgery (16 days) or primary amputation (18 days). The complication rate of PTA requiring surgery was 5.5 per cent. CLI represents a large non-elective workload for a vascular unit. The increasing use of non-invasive duplex assessment and angioplasty plays a major part in the successful management of these patients.

Lower extremity arterial injury: Results of 550 cases and review of risk factors associated with limb loss

Purpose: We sought to analyze the results of lower limb arterial injury (LLAI) management in a busy metropolitan vascular unit and to identify risk factors associated with limb loss. Patients and Methods: Between 1987 and 1997, prospectively collected data on 550 patients with 641 lower limb arterial injuries were analyzed. Results: The mechanism of LLAI was gunshot wounds in 46.1%, blunt in 19%, stabbing in 11.8%, and shotgun in 9.1%. The most frequently injured vessel was the superficial femoral artery (37.2%), followed by the popliteal (30.7%), crural (11%), common femoral (8.7%), and deep femoral (5.3%) arteries. In 3.4% of cases, there was a combined injury on either side of the knee (ipsilaterally). Associated injuries included bony injury in 35.1% of cases, nerve injury in 7.6%, and remote affecting the head, chest, or abdomen in 3.6%. Surgery was carried out on 96.2% of cases with a limb salvage rate of 83.8% and a survival of 98.5%. In spite of a rising trend in LLAI, our total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant ( P < .01) independent risk factors for amputation were occluded graft (odds ratio [OR] 16.7), combined above- and below-knee injury (OR 4.4), tense compartment (OR 4.2), arterial transsection (OR 2.8), and associated compound fracture (OR 2.7). Conclusion: LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputations, whereas high-velocity firearm injuries are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization. (J Vasc Surg 2001;33:1212-9.)

Upper limb arterial injuries: experience of 713 patients and analysis of risk factors associated with limb loss

Abstract Background Experience of upper limb arterial injury management was analysed and risk factors associated with limb loss were identified. Methods Between 1987 and 1997, data on 713 patients with 760 upper limb arterial injuries were analysed retrospectively. Results The mechanism of injury was stabbing in 52 per cent, gunshot in 23 per cent, blunt trauma in 14 per cent and shotgun in 5 per cent. The most frequently injured vessel was the brachial artery (53 per cent) followed by the axillary (20 per cent), subclavian (14 per cent), radial (7 per cent) and ulnar (6 per cent) arteries. Associated injuries included bony injury in 12 per cent, nerve injury in 39 per cent and remote injury affecting the head, chest or abdomen in 3 per cent. Surgical revascularization was carried out in 95 per cent of patients and arm fasciotomy was necessary in 9 per cent. The limb salvage rate for this series was 96 per cent (27 amputations) and the survival rate was 98 per cent (11 deaths). On stepwise logistic regression analysis, significant (P &amp;lt; 0·01) independent risk factors for amputation were blocked graft (odds ratio (OR) 7·6), tense compartment at presentation (OR 6·5), neurological deficit at presentation (OR 5·4) and associated compound fracture (OR 5·4). Conclusion Despite good collateral circulation, upper limb arterial injuries carry a considerable risk of limb loss, particularly when associated with soft tissue damage.

Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss

Abstract Background The authors' experience of lower limb arterial injury (LLAI) management was analysed and risk factors associated with limb loss were identified. Methods Between 1987 and 1997, data on 550 patients with 646 LLAIs were analysed retrospectively. Results The mechanism of LLAI was gunshot wounds in 46 per cent, blunt trauma in 19 per cent, stabbing in 12 per cent and shotgun in 9 per cent. The most frequently injured vessel was the superficial femoral artery (37 per cent) followed by the popliteal (31 per cent), crural (11 per cent), common femoral (9 per cent) and profunda (59 per cent) arteries. In 3 per cent of patients there was a combined injury on either side of the knee. Associated injuries included bony injury in 35 per cent, nerve injury in 8 per cent and remote injuries affecting the head, chest or abdomen in 4 per cent. Surgery was carried out in 96 per cent of patients with a limb salvage rate of 84 per cent and a survival rate of 98 per cent. Despite a rising trend in LLAI, total and delayed amputation rates remained stable. On stepwise logistic regression analysis, significant (P &amp;lt; 0·01) independent risk factors for amputation were blocked graft (odds ratio (OR) 16·7), combined above- and below-knee injury (OR 4·4), tense compartment at presentation (OR 4·2), arterial transection (OR 2·8) and associated compound fractures (OR 2·7). Factors such as simple fractures, venous injury/ligation and the use of synthetic grafts were not associated with increased risk of limb loss. Conclusion LLAI carries a high amputation rate. Stab injuries are the least likely to lead to amputation whereas injuries associated with severe soft tissue damage, such as high-velocity firearm injuries and blunt trauma with compound fractures, are the most likely to do so. The most significant independent risk factor for limb loss was failed revascularization.