Vascular Amputation Research Articles

Body schema and body awareness of amputees

The phantom phenomenon is a well-known example of the difference between body awareness and body schema. The present study is aimed at showing how body changes and prosthesis use are reflected in body schema and body awareness-the latter relating to the image that various amputees have of their bodies. (i) Examining the configuration of body schema: A trial examining the spatial location of the phantom limb (50 people with lower or upper limb loss); (ii) examining the functional aspect of body schema: The distribution of weight power between intact and prosthetic limbs (34 people with tibial amputation); (iii) examining body awareness: Body Focus Questionnaire by Fisher (44 people with lower limb amputation, 33 intact people); and (iv) Questionnaire on anamnesis- and prosthesis-wearing habits (people participating in research methods [i] and [iii] mentioned above). We found that when the amputees wore their prostheses, the configuration of body schema did not change, however, the people who had not used their prosthesis for a long period of time (in our study, at least for six years), the phantom limb shortened, a phenomenon known as telescoping. The functional adaptation of the prosthesis to the body schema starts in a short time (within two weeks) after wearing it, and it becomes close to normal in carrying body weight after a longer period of time (two years). In the beginning phase of rehabilitation, the awareness of legs is similar to that of the control group, while later on it this awareness decreases. Over time, however, the lost limb, regardless of having a prosthesis or not, loses its importance. People with a more serious or vascular amputation of the upper limbs have a clearer image of them. Limb parts having a greater cortical representation appear more intensively in phantom sensations, while the strength of the cortical representation in body schema has no significance. From both configuration and functional aspects, wearing a prosthesis helps maintain a body schema in which the phantom limb remains similar to the intact one, which can be explained by the connectional schema model. This is needed for movements to be carried out properly. Although the amputee can see the prosthesis and senses the phantom limb, they do not consider it their own since they are aware of the loss. Therefore, the fact that a prosthesis is worn will not be represented in body awareness as the highest level of mental structure.

Major Amputation Incidence Decreases Both in Non-Diabetic and in Diabetic Patients in Helsinki

The aim of the study was to assess the changes in diabetes-related lower extremity amputations and to compare it with the development of amputations for critical leg ischaemia in patients without diabetes. Clinical records of 1094 patients undergoing major lower limb amputations for vascular disease in the town of Helsinki during 13 years from 1990 to 2002 were analyzed retrospectively. Data concerning patient factors, diagnosis, existence of diabetes and amputation level were recorded. The study period was divided into three parts (1990-1994, 1995-1998 and 1999-2002) and results were compared between diabetic and nondiabetic vascular amputees during these time periods. From 1990 through 2002, 561 of patients undergoing major lower limb amputation had diabetes mellitus. The overall incidence of major amputations of diabetics reduced from the first time period to the last period by 23%. At the same time, the incidence of amputations in non-diabetic patient group decreased 40%. If the incidence rate for amputations is expressed per million individuals with diabetes, 33% decrease was observed during the study period. The decrease in major amputation rates among diabetic as well as non-diabetic patients can be attributed to the increased interest in amputation prevention, with a contribution by vascular surgeons being made in both groups.

Secondary Prevention of Arteriosclerosis in Lower Limb Vascular Amputees: A Missed Opportunity

To determine the numbers of patients with peripheral vascular disease prescribed secondary prevention agents following a lower limb amputation. A retrospective cross sectional study. The clinical documentation of 107 vascular amputees (mean age 69.5, 2:1 male:female ratio) referred for prosthesis provision in 2004 and 2005 were analysed to determine levels of prescribing of anti-platelet agents, anti-coagulants and cholesterol lowering drugs. Analysis of vascular amputees referred in 2004 and 2005 reveals that 41% were prescribed a statin and 39% were prescribed a statin and 60% an anti-platelet agent. While 39% of these patients were on both drugs, 32% had been prescribed neither. The medical management of patients with severe peripheral vascular disease, even where their disease has led to an amputation, is sub-optimal.

John Collins Warren: Master Educator and Pioneer Surgeon of Ether Fame

John Collins Warren (1778–1856) represented the apex of surgery and medicine of the first half of nineteenth century Boston. Educated at Harvard College where he obtained a Bachelor of Arts in 1797, he contemplated the idea of a business career prior to setting sail for a traditional medical education at Europe's finest universities. From 1799 to 1802, he attended prestigious medical and surgical lectures in London, Edinburgh, and Paris. Warren received an honorary MD from Scotland's St. Andrews University in 1802. He then returned to Boston and joined his father's practice.In 1815, he followed his accomplished father as the Hersey Professor of Anatomy and Surgery at Harvard Medical School. He held this position with great distinction until 1847 when he retired as professor emeritus. From 1816 to 1819 he served as Harvard Medical School dean and received an honorary medical degree at the end of his term.John Collins Warren had numerous surgical accomplishments during his illustrious career. Clinically, he was active and varied in his practice, operating on strangulated hernias, tumors, and cataracts, in addition to performing vascular surgery and amputations. He published many articles and books of widespread circulation. Professor Warren also performed the first reported case of ether anesthesia administered by William T. Morton on October 16, 1846.Outside the operating theatre, Doctor Warren and his colleagues were revered for founding the Massachusetts General Hospital in 1821, and years before, in 1812, Warren and his associates established the New England Journal of Medicine and Surgery. In light of his varied contributions, John Collins Warren is remembered as a dedicated and innovative surgeon, as well as a committed medical educator, able administrator and effective leader.

Success rates for rehabilitation of vascular amputees: implications for preoperative assessment and amputation level.

All lower limb amputations performed during 1986 and 1988 in eight hospitals in the south-east region were assessed. Of 440 amputations for vascular disease, 193 were above-knee, 193 below-knee, 15 Gritti-Stokes, 15 through-knee and 24 bilateral. Of the 440 patients, 75 died in hospital, 113 were considered unsuitable for a prosthesis and 252 (57 per cent) were referred for prostheses. Rehabilitation questionnaires were sent to 179 patients (41 per cent), as a further 54 had died and 19 had become known non-wearers before the study commenced. The response rate was 81 per cent; 102 patients completed the questionnaire, 21 were reported dead, and 22 were non-wearers. Of a maximum rehabilitation score of 12, 52 patients scored 6 or more (consistent with mobility on their artificial limb around the home), and 21 scored 9 or more (a standard accepted as successful rehabilitation). It is concluded that 10-15 per cent of amputees achieve mobility around the home on their prosthesis. Only 5 per cent, however, rehabilitate well and become independent of their wheelchair. When amputation is inevitable, more consideration should be given to surgery that optimizes wheelchair rehabilitation.

Skew flap myoplastic below-knee amputation: a preliminary report.

Abstract A preliminary report is made of a modified technique of below-knee amputation using skewed sagittal skin flaps, combined with a posterior myoplasty. The satisfactory initial shape eliminates any delay for maturation of the stump and allows early casting of the socket for a prosthesis which can be worn within 3 weeks of operation for non-vascular amputations and within 4 weeks for vascular amputations. Forty-seven of these amputations have been performed; 4 patients required re-amputation at a higher level and 6 required secondary minor revision before full healing was achieved. In the remaining patients healing was uneventful.

Comparison of Quality of Life of Persons Who Have Experienced Amputations and Persons Who Have Had Bowel Resections

Comparing the quality of life of persons who have experienced amputations and persons who have had bowel resections illustrates the impact of chronic disease upon all aspects of a patient's life. Because the purpose of nursing research is to bring about knowledge to better direct patient care, understanding the impact of chronic illness contributes to an improvement in the quality of life of these patients. By appreciating the patient's perspective concerning the illness, the nurse can better educate the patient in all aspects of the disease process. Based on Jean Watson's Theory of Human Caring, this study acknowledged the need for evidence-based nursing practice to care for the well-being of the patient in a holistic manner. Our hypothesis was adult patients after Crohn disease-related bowel resection experience a better quality of life than do adult patients with peripheral vascular disease related amputation. This descriptive comparative study had a sample of patients with Crohn disease and resection (n = 28) and patients with peripheral vascular amputation (n = 16). The instrument used to measure quality of life was the RAND-36 Item Health Survey 1.0. Results revealed significant differences between the patients with bowel resection and those with peripheral vascular amputation with regard to physical functioning, general health, and role limitations related to physical health. No significant differences existed between the two groups in terms of energy/fatigue, emotional well-being, social functioning, role limitations related to emotional problems, and pain. Results from the data may indicate that the incorporation of more education regarding social, emotional, physiological, and psychological aspects of postoperative life may be of importance to evidence based nursing practice. This addition may also lead to better adjustment to postoperative life for patients and improve overall quality of life.

Are there predictors for the outcome of a PGE1 treatment in peripheral arterial disease with critical limb ischaemia?

In a multivariate retrospective analysis was conducted to examine whether and to what extent PGE1 is therapeutically effective and whether there are predictors of response. The examination included 767 patients (448 women, 319 men) of a mean age of 71.2 years and with peripheral arterial disease (PAD) having existed for 44.7 months on the average. They suffered from critical limb ischaemia (Fontaine's stages III/IV) and showed average tcpO2 values at the instep of 2 mmHg (0 to 15) and average systolic malleolar artery pressures of 18 mmHg (0 to 35 mmHg). Between 1989 and 2001, the patients had received treatments in hospital with i.v. PGE1 doses (2x20 microg or 1x60 microg/day) for an average of 34.2 days (mean of responder- and non-responder group). Patients were called responders when pain had markedly decreased or disappeared, necroses had been reduced or healed completely, and vascular reconstruction, PTA or amputations were not necessary. The clinical analysis showed 82.4% of the patients to be responders and 17.6% to be non-responders. It was demonstrated that the outcome of the therapy was not dependent on the supine or sitting tcpO2, the malleolar artery pressure, the patient's age or sex, the duration of PAD, the number or kind of concomitant diseases, the patient's general condition, the localization and number of vascular occlusions, the kind of prior therapy, or the number of previous amputations, although differences in some of the parameters, while clinically irrelevant, were found to be statistically significant. They are not predictors of the outcome of a PGE, therapy. Even in extremely bad haemodynamic situations at the beginning of a therapy (malleolar artery pressures from 0 to 35 mmHg, tcpO2 0 to 15 mmHg, multilevel occlusive disease, multiple previous operations and concomitant diseases), PGE, therapies of more than 20 days - on the average 35.6 days (mean of responder group) - duration allow clinically relevant positive results to be achieved.

Bilateral changes in somatosensory sensibility after unilateral below-knee amputation

Kavounoudias A, Tremblay C, Gravel D, Iancu A, Forget R. Bilateral changes in somatosensory sensibility after unilateral below-knee amputation. Arch Phys Med Rehabil 2005;86:633–40. Objective To evaluate possible alteration in proprioceptive and cutaneous sensibility in the nonamputated leg of unilateral transtibial amputees. Design Cross-sectional study with between-subjects (amputees vs controls) and within-subjects (nonamputated vs amputated leg) comparisons. Setting Canadian rehabilitation hospital research laboratory. Participants Two groups of amputees (34 due to traumatic causes, 14 due to vascular causes), recruited more than 1 year after their prosthetic training; and 2 groups (n=34, n=14) of age-matched control subjects. Interventions Not applicable. Main outcome measures Threshold of movement detection and touch-pressure perception at the knee and foot levels. Results In the traumatic group, the sensory thresholds of the nonamputated leg were significantly higher than the control values in the 2 modalities tested. The movement detection was reduced at the knee and ankle levels, whereas a decrease in touch-pressure sensibility was observed only at the plantar site. As expected, a large proportion of the vascular amputees presented with severe sensory deficits in the nonamputated leg, particularly a loss in touch-pressure perception at the foot. The thresholds of movement detection were similar and correlated at both knees in the 2 groups of amputees. For the touch-pressure thresholds, no significant relationship was found between sides at the knee level. Conclusions Sensory changes observed in the nonamputated leg suggest that central sensory adaptations occur after amputation. For movement detection, they were marked by a matching of perception on both sides of the body. Functional significance of these changes remains to be determined.

Rehabilitation of the geriatric vascular amputee patient: A population-based study

Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001;82:776-9. Objectives: To determine the rate of successful prosthetic fitting in geriatric vascular amputees in the community and to determine predictors of successful fit. Design: Epidemiologic survey. Setting: General community, Olmsted County, Minnesota. Patients: All Olmsted County residents more than 65 years old who had a major lower extremity amputation (below knee amputation [BKA] or higher) for peripheral vascular disease between 1974-1995, of whom 199 were identified. Median age at amputation was 79.7 years with a median survival of 1.5 years. Intervention: A retrospective chart review. Main Outcome Measure: Successful prosthetic fit. Results: Amputation levels were: 64% BKA, 4.5% knee disarticulation, 31% above knee amputation (AKA), and 0.5% hip disarticulation. Only 36% of the population was successfully fitted, compared with 74% of patients referred to the Amputee Clinic. Major reasons for not being fitted included death, reamputation, cerebrovascular disease, and cognitive deficits. Increased age (p <.001), cerebrovascular disease (p <.001), dementia (p =.002), and AKA (p <.001) were associated with failure to fit. Conclusion: The high probability of successful prosthetic fitting reported among referral practices cannot be generalized to unselected elderly individuals. However, selected individuals can successfully be fitted with a prosthesis; knowledge of predictors of prosthetic fitting may facilitate setting of realistic goals during presurgical counseling in this age group.

CARDIOVASCULAR DISEASE RISK FACTORS IN AN AMPUTEE POPULATION

Cardiovascular disease, which remains the number one cause of death in the United States is particularly prevalent in amputees and certain other groups. The objective of this study was to identify the underlying risk factors of cardiovascular disease in an amputee population and to determine if those risk factors differ between the vascular and nonvascular amputee groups. In addition, the amputee risk profile was compared with the general population. A survey consisting of previously validated cardiovascular disease risk factor questions was sent to 39 support groups across the United States. From the data of 170 respondents, four highly prevalent risk factors were identified in the amputee profile; these factors included high cholesterol, hypertension, diabetes and inactivity. The vascular amputees were significantly older than the nonvascular amputees had an increased occurrence of diabetes (71% versus 13%; p = 0.001), an increased overweight prevalence (71% versus 29%; p = 0.019) and a decreased number of days per week of alcohol consumption (.64 vs. 1.24; p = 0.018). Additionally, it appeared that three risk factors were elevated above the United States population norms for the following categories; these factors included cholesterol, hypertension, and diabetes. The results of this study indicate that special attention should be focused on the modification of risk factors emphasizing high cholesterol, hypertension, diabetes and inactivity. The high occurence of reported risk factors could explain the increased rate of death as a result of cardiovascular disease in the amputee population. Supported by Georgia Southern University Research Services and Sponsored Programs.

The Effect of Age, Gender, Risk Level and Glycosylated Hemoglobin in Predicting Foot Amputation in HMO Patients with Diabetes

To determine if age, gender, risk level and glucosylated hemoglobin could predict foot amputations in HMO patients with diabetes. A retrospective chart review of a non-random sample of 27 patients with amputation and 110 randomly selected patients without amputation during the same time period. Chi-square, t-tests and logistic regression were used to analyze the data. There was no significant difference between the group with amputation and those without amputation in age or gender. However, there was a significant difference between the two groups in the risk stratification (p = .005) and glycosylated hemoglobin levels (p = .058). Nurse practitioners can effectively screen for amputation risk factors and closely monitor glycosylated hemoglobin levels of diabetic patients to reduce the incidence of vascular complications and related lower extremity amputation.

THE DIABETIC FOOT PROJECT OF FLANDERS, THE NORTHERN PART OF BELGIUM: IMPLEMENTATION OF THE ST VINCENT CONSENSUS. SENSIBILISATION AND REGISTRATION IN DIABETES CENTRES.

As a result of the St Vincent declaration, a Belgian "task force" was installed in 1992 and consequently 16 working groups were formed. They presented their objectives in 1995. The working group "prevention and treatment of diabetic foot lesions" started the implementation of a screening program to obtain an overview of the presentation of diabetic foot lesions, the amputation rate and the prevalence of patients with a foot at risk. This study reports the results from 43 out of 73 Flemish diabetes centres. 1653 patients were enrolled in this study (53% women, 47% men, median age 61). 34.6% were type 1 and, 65.4% type 2. One or more arterial pedal pulses were absent in 28%, 30.5% had an abnormal monofilament test, 35% skin lesions and 28% malformations. Still 19% smoked, 15.8% had visual problems and 11% had already developed an ulcer previously. Ulcers were reported in 8.7% of which almost 2/3 belonged to Wagner class I. 69 (3.87%) of the patients had had amputations. According to the four-risk categories-scale 46.3% of the patients belonged to the highest one; peripheral vascular disease, previous amputations, previous ulcers, and Charcot joints. In our region we didn't have previous data on the prevalence and morbidity of the amputation rate with diabetes patients. We observed 3.87% amputations, which is rather high in comparison with international data (0.44% - 2.4%). The general follow-up of diabetic foot problems can be organised in co-operation with other care providers. A national program therefore is going to start in the next months. We all have to be aware of the size of the problem to offer the best possible prevention. As we have seen, the use of inlay soles and podiatrist-made ortheses for example is very low. We hope that all care providers will participate in this important project, so that they will acquire a specific attitude towards these patients. In daily clinical practice there are some key-roles to be respected by all health care providers. In our opinion the next are of the utmost importance: take off your diabetic patient's shoes when they visit you; give specific education if your patient has a foot at risk; if an ulcer is present, carefully follow-up is mandatory and if no good evolution of the ulcer is seen, an early referral to a diabetic foot clinic is obvious. Together we can lower down the amputation rate of diabetic foot lesions. And that would be a marvelous implementation of the St Vincent declaration in Belgium.

Cardiovascular Disease Risk Factors in an Amputee Population

Cardiovascular disease, which remains the number one cause of death in the United States, is particularly prevalent in amputees and in other groups such as men, the elderly, and African Americans. The objective of this study was to identify the underlying risk factors of cardiovascular disease in an amputee population and to determine if those risk factors differ between the vascular and nonvascular amputee groups. In addition, the amputee risk profile was compared with the general population. A survey consisting of previously validated cardiovascular disease risk factor questions was sent to 39 support groups across the United States. From the data of 170 respondents, four highly prevalent risk factors were identified in the amputee profile; these factors included high cholesterol, hypertension, diabetes, and inactivity. The vascular amputees were significantly older than the nonvascular amputees and had an increased occurrence of diabetes (71% versus 13%; p = 0.001), an increased overweight prevalence (71% versus 29%; p = 0.019), and a decreased number of days per week of alcohol consumption (0.64 versus 1.24; p = 0.018). Additionally, it appeared that three risk factors were elevated above the United States population norms for the following categories; these factors included cholesterol, hypertension, and diabetes. The results of this study indicate that special attention should be focused on the modification of risk factors emphasizing high cholesterol, hypertension, diabetes, and inactivity. The high occurrence of reported risk factors could explain the increased rate of death as a result of cardiovascular disease in the amputee population.

Lower limb prosthesis utilisation by elderly amputees.

The goal of prosthetic rehabilitation is to compensate for the loss of a limb by amputation by, in the case of a lower limb, encouraging walking, and to achieve the same level of autonomy as prior to the amputation. However, because of difficulties walking, elderly amputees may use their prosthesis to a greater or lesser degree or simply stop using it during the rehabilitation period. The objective of this research was to study factors such as physical and mental health, rehabilitation, physical independence and satisfaction with the prosthesis to understand why amputees use their prosthesis or not. The sample was composed of 65 unilateral vascular amputees 60 years old or over living at home. The information was collected from medical records, by telephone interview and by mail questionnaire. Prosthesis use was measured by a questionnaire on amputee activities developed by Day (1981). Eighty-one per cent (81%) of the subjects wore their prosthesis every day and 89% of this group wore it 6 hours or more per day. Less use of the prosthesis was significantly related to age, female gender, possession of a wheelchair, level of physical disability, cognitive impairment, poorer self-perceived health and the amputee's dissatisfaction. A multiple regression analysis showed that satisfaction, not possessing a wheelchair and cognitive integrity explained 46% of the variance in prosthesis use.

Body image and patients with amputations: does the prosthesis maintain the balance?

This paper attempts to establish whether dissatisfaction with the artificial limb and/or body image relate to achieved mobility following lower limb amputation in established limb wearers. Patients attending limb fitting clinics (n = 107, 62% male, mean time from amputation 13.9 years; range 1-54) participated. The measures were a specially designed Attitude to Artificial Limbs Questionnaire, a Body Image Questionnaire adapted from an eating disorders instrument including reference to body shape, the Hospital Anxiety and Depression Scale and the Harold Wood Stanmore Mobility Scale. The rehabilitation physician rated prosthetic suitability on a Numerical Rating Scale. The results showed patients were moderately satisfied with their artificial limb, had little experience of body image disruption or distress and there was no overall relationship between these variables and mobility. However, those with a more negative body image were more anxious and in younger patients who sustained more traumatic than vascular amputations, the correlation between body image and mobility was significant, anxiety was higher and physician satisfaction with the prosthesis was lower. It is concluded that body image disruption, anxiety and depression are not common in established limb wearers except in young people with traumatic amputations.

Muscle metabolism changes with training in the nonamputated limb after vascular amputation: Interest of phosphorus 31 NMR spectroscopy

Objective: To determine by 31P nuclear magnetic resonance (NMR) spectroscopy the efficacy of training in improving aerobic metabolism of calf muscle in nonamputated limb after recent vascular amputation; to assess the possible associated microcirculatory changes; and to evaluate the need for noninvasive monitoring techniques during training in the nonamputated limb after recent vascular amputation. Design: Prospective study, before and after training. Subjects served as their own controls and were compared with a control group. Setting: Rehabilitation center of a university hospital. Patients: Ten unilateral vascular amputated patients were included with ankle systolic index between 0.5 and 0.8 in the nonamputated limb, and 10 control subjects without cardiovascular disease or risk factors of atherosclerosis with ankle systolic index of >.95. Intervention: Walking with prosthesis at self-selected velocity over increasing walking distance, arm training at a workload of 60% of a maximal arm test, and analytical exercises of the nonamputated leg (dynamic contractions against low resistance). Subjects received training as inpatients, 5 days a week. Main Outcome Measures: Before and after training, ankle systolic index, forefoot transcutaneous oxygen tension (TcPo 2) and veno-arteriolar reflex, and digital plethysmography of the second toe with reactive hyperemia test were studied. Changes in calf muscle pH, phosphocreatine (PCr), and inorganic phosphate (Pi) were measured by 31P NMR spectroscopy at rest and during a plantar flexion-type incremental protocol. Results: There was no significant difference in ankle systolic index (.63 ± .10 vs .64 ± .07) or in TcPo 2 (42 ± 11 vs 44 ± 10mmHg), and there was reappearance of veno-arteriolar reflex in 3 cases, of a plethysmographic signal in 2 cases, and of the positivity of the reactive hyperemia test in 3 cases. No differences were found with 31P NMR spectroscopy at rest before and after training. At the same workload (1 watt) the difference of the ratio (PCr/(PCr + Pi)) of rest to effort (PCr depletion) was significantly increased in the amputated patients (.423 ± .159 vs .145 ± .058; p < .01). This difference of ratio was lower after training (.360 ± .158 vs .423 ± .159; p < .05). The pH was less acid between the two periods. Conclusion: Vascular monitoring with systolic index and TcPo 2 is necessary to follow and to prevent serious ischemia of the nonamputated limb. Claudication is often not detected because of early exhaustion during walking. Training after recent vascular amputation improves the skeletal muscle oxydative capacity.

Predicting the use of prostheses by vascular amputees

To evaluate our accuracy in predicting the use of prostheses by patients undergoing major lower limb amputation. Prospective study, with multiple assessors, "blind" to the predictions made by each other. Sixty-one patients (35 male: age 51-91, median 79) having their first major lower limb amputation. Five members of the rehabilitation team (surgeon, specialist in prosthetics, nurse, physiotherapist and occupational therapist) each recorded predictions of prosthetic use and mobility before amputation and during the first 2 weeks thereafter. Patients were followed up 6-24 months later. At follow-up 17 patients had died. Of the remaining 44 (25 below-knee and 19 above-knee amputees), 23 of 27 (85%) who had been predicted as using prostheses were doing so, while only 11 of 17 (65%) had been correctly predicted as non-users. Nevertheless, only two of the patients not using prostheses contrary to prediction had ever had prostheses made for them, and both had developed problems with the other leg at a later date. Different members of the rehabilitation team were similar in their ability to predict outcome. Inappropriate fitting of prostheses can be kept to a minimum by a team approach to rehabilitation, but amputees may defy careful prediction by the development of new medical problems.

Procedures and techniques in intensive care

Procedures and techniques in intensive care

Operations, total hospital stay and costs of critical leg ischemia: A population-based longitudinal outcome study of 321 patients

In a longitudinal analysis of all 321 patients in a defined population having surgery for critical leg ischemia during 1 year in Malmöhus county (0.53 million inhabitants), Sweden, we investigated all vascular procedures and amputations on both legs, total hospital stay and hospital costs from the first procedure in each patient until death or at follow-up at least 6 years postoperatively. The first (key) operation during the inclusion year was a reconstructive vascular procedure in 96 patients, a restorative vascular procedure in 111 and a major amputation in 114 patients. One third of those with a reconstructive and half of those with a restorative key procedure had an ipsilateral major amputation. The mean number of surgical procedures and length of hospital stay among all patients were 3 (1-19) procedures and 117 (1-1097) days, respectively. Of the total number of days in hospital, less than half were in surgical departments, 10% in other acute-care departments and almost half in rehabilitation clinics and nursing homes. The total hospital and surgical costs among all patients were USD 15.1 million (mean USD 47,000/patient), with no significant differences in relation to the key operation. We conclude that patients who have undergone surgery for critical leg ischemia accumulate very high total long-term hospital costs due to the need for repetitive surgery and long hospital stays. Our findings also show that a longitudinal study, including hospital stay in departments other than surgical, is necessary for a correct cost-and-outcome analysis.