Multidisciplinary Limb Salvage Care is Associated with Decreased Mortality Without Increasing Revascularization In Major Amputations
Qingwen Kawaji, James Martinson, Sharmeen Husain, Jason Howard, Darshan Randhawa, Michael Rouse, Suzanne Kool, Jason A Chin, Raghuveer Vallabhaneni, Jason R Crowner
Medstar, Baltimore, MD
Objective:Development and implementation of a limb salvage program has been shown to improve amputation free survival and reduce need for major amputations; however, the impact of this approach on patients who eventually progress to major amputation is unclear. The goal of this study is to assess the effect of a multidisciplinary limb salvage team on revascularization rates prior to amputation and post-amputation outcomes in patients undergoing major lower extremity amputations in an urban setting.
Methods:Patients in a single health-care system who underwent major lower extremity amputations between 2014 and 2021 were identified using Current Procedural Terminology (CPT) codes within our electronic medical records. Patient demographic data, comorbidities, pre-amputation revascularization, limb-salvage procedures, and one year mortality were collected by chart review. Chi-square tests, Mann-Whitney U test and student’s t-test were used to compare patient variables between pre- and post- launch of a multidisciplinary limb-salvage team. Univariate and multivariate logistic regression analysis were used to assess patient characteristics associated with 30-day pre-amputation revascularization and one year mortality.
Results:509 patients underwent major lower extremity amputations during the study period: 48% below knee amputations (BKA), 50% above knee amputations (AKA). Comparing pre-amputation revascularization procedures stratified by involvement of a multi-disciplinary limb salvage team, there was no significant difference in 30-day revascularization rate (30.8% vs. 30.1%, p=0.87). Pre-amputation revascularization rates at 90 days (22.7% vs. 22.5%, p=0.95) and one year (21.6% vs. 16.9%, p=0.19) remained similar between groups as well. There was a statistically significant increase in 30-day pre-amputation debridement/minor amputation (0.33 vs. 0.69, P<0.001) after limb salvage implementation; this significant increase was also shown at 90 days and one year prior to amputation (Table 1). One year mortality rates in both AKA (55% vs. 10%, p<0.001) and BKA (49% vs. 6.5%, p<0.001) groups were significantly different after limb salvage implementation. Patient characteristics associated with 30-day pre-amputation revascularization included hypertension (OR 2.1, 95% CI 1.2-3.8), diabetes (OR 0.53, 95% CI 0.34-0.80), and smoking status (OR 1.7, CI 1.1-2.6). Patients with end stage renal disease (ESRD) had higher one year mortality (OR 2.1, 95% CI 1.2-4.0). Implementation of limb salvage program was associated with improved one-year post-amputation mortality overall (OR 0.09, 95% CI 0.049-0.17) (Table 2).
Conclusion:For patients with chronic limb threatening ischemia (CLTI) who eventually progressed to require major lower extremity amputations, implementation of a limb salvage program did not change pre-amputation revascularization practice. However, it was associated with significantly improved one-year post-amputation mortality. Our findings further support the global vascular guidelines, demonstrating the benefit of limb salvage services in patients with major amputations.
Table 1: Revascularization and Minor Amputation Performed Overall and Stratified by Limb-salvage Status.
| level | All | Pre | Post | p-value | |
| Total Patients | 509 | 273 | 236 | ||
| Revas 30 days (%) | Yes | 155 (30.5%) | 84 (30.8%) | 71 (30.1%) | 0.87 |
| No | 354 (69.5%) | 189 (69.2%) | 165 (69.9%) | ||
| Endo 30 days (%) | Yes | 104 (67.1%) | 54 (64.3%) | 50 (70.4%) | 0.48 |
| No | 51 (32.9%) | 30 (35.7%) | 21 (29.6%) | ||
| Revas 30-90 days (%) | Yes | 115 (22.6%) | 62 (22.7%) | 53 (22.5%) | 0.95 |
| No | 394 (77.4%) | 211 (77.3%) | 183 (77.5%) | ||
| Endo 30-90 days (%) | Yes | 74 (64.3%) | 41 (66.1%) | 33 (62.3%) | 0.58 |
| No | 41 (35.7%) | 21 (33.9%) | 21 (37.7%) | ||
| Revas 90 days-1yr (%) | Yes | 99 (19.4%) | 59 (21.6%) | 40 (16.9%) | 0.19 |
| No | 410 (80.6%) | 214 (78.4%) | 196 (83.1%) | ||
| Endo 90 days-1yr (%) | Yes | 57 (57.6%) | 30 (50.8%) | 27 (67.5%) | 0.1 |
| No | 42 (42.4%) | 29 (49.2%) | 13 (32.5%) | ||
| Number of wound debri local amp 30 days (median [IQR]) / Mean(SD) | 0.00 [0.00, 1.00]0.48 (0.78) | 0.00 [0.00, 1.00]0.33 (0.64) | 1.00 [0.00, 1.00]0.69 (1.0) | <0.001 | |
| Number of wound debri local amp 90 days (median [IQR]) / Mean(SD) | 0.00 [0.00, 0.00]0.31 (0.79) | 0.00 [0.00, 0.00]0.25 (0.62) | 0.00 [0.00, 0.00]0.84 (1.5) | <0.001 | |
| Number of wound debri local amp 90 days 1 year (median [IQR]) | 0.00 [0.00, 0.00]0.21 (0.77) | 0.00 [0.00, 0.00]0.16 (0.53) | 0.00 [0.00, 0.00]0.56(1.8) | <0.001 |
Table 2: Logistic Regression Assessing Patient Characteristics Associated with One Year Mortality after Major Amputation
| Variables | Adjusted OR | 95% CI | P value |
| Age | 1.0 | (1.0, 1.1) | 0.051 |
| Sex: Male | Ref | Ref | Ref |
| Sex: Female | 0.97 | (0.56, 1.7) | 0.91 |
| Race: Black | Ref | Ref | Ref |
| Race: White | 0.98 | (0.54, 1.8) | 0.95 |
| Race: Other | 0.61 | (0.084, 4.4) | 0.62 |
| Insurance: Medicare | Ref | Ref | Ref |
| Insurance: Medicaid | 0.81 | (0.39, 1.7) | 0.59 |
| Insurance: Private | 1.9 | (0.65, 5.7) | 0.24 |
| Insurance: Self Pay | 0.69 | (0.091, 5.3) | 0.72 |
| Income: Q1 | Ref | Ref | Ref |
| Income: Q2 | 1.20 | (0.66, 2.2) | 0.55 |
| Income: Q3 | 1.02 | (0.47, 2.2) | 0.97 |
| Income: Q4 | 0.46 | (0.11, 1.9) | 0.28 |
| HTN | 1.0 | (0.49, 2.2) | 0.93 |
| HDL | 1.5 | (0.85, 2.6) | 0.16 |
| DM | 1.2 | (0.69, 2.2) | 0.48 |
| ESRD | 2.1 | (1.2, 4.0) | 0.013 |
| CAD | 1.0 | (0.58, 1.7) | 0.99 |
| Smoker | 1.2 | (0.71, 2.2) | 0.44 |
| Amputation: AKA | Ref | Ref | Ref |
| Amputation: BKA | 0.72 | (0.42, 1.2) | 0.22 |
| Amputation: TKD | 0.87 | (0.093, 8.2) | 0.91 |
| Pre-Limb Salvage | Ref | Ref | Ref |
| Post-Limb Salvage | 0.090 | (0.049, 0.17) | <0.001 |
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