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Major Amputations: The Compound Risk of Peripheral Arterial Disease and Minor Amputation
Megan E Lombardi, Alexis Betancourt, Claudia Theis, Ehsan Benrashid, William Marston, Mark Farber, Luigi Pascarella
University of North Carolina - Chapel Hill, Chapel Hill, NC
Introduction Foot ulcers and minor amputations are significant complications associated with peripheral arterial disease (PAD), with the presence of diabetes further elevating this risk. During assessment, it is crucial to consider comorbidities, vascular status, and operative history to guide treatment recommendations effectively. This study examines the influence of PAD and revascularization on the likelihood of major amputation following a minor amputation.
Methods We conducted a retrospective review of patients who underwent minor lower extremity amputation at a tertiary referral center between 2017 and 2022. Limbs were identified using five CPT codes and followed for one year after the index procedure. Data collected included demographics, comorbidities, wound characteristics, wound, ischemia, and foot infection (WIfI) stage, as well as revascularization attempts (endovascular, open, or diagnostic-only). The primary outcomes were major amputation at 30-days, 6-months, and 1-year, and all-cause mortality at 1-year with the primary exposure being PAD. Crude amputation risk was estimated using generalized estimating equation (GEE) models. Multivariable logistic regression identified independent predictors of amputation, while Cox proportional hazards models evaluated time to amputation. Kaplan-Meier analysis was used to estimate 1-year amputation-free survival, with group differences tested by the log-rank test.
Results A total of 973 limbs from 861 patients (mean age 60 ± 13 years, 32.8% female) were included. PAD was present in 46.0% of the limbs. At 1-year, the overall major amputation rate was 11.5% and mortality was 10.6%. Limbs with PAD had higher crude amputation rates than those without (16.3% vs 7.3%, p < 0.001). Kaplan-Meier analysis showed shorter amputation-free survival in PAD versus non-PAD limbs (324 ± 5 vs 348 ± 3 days, log-rank p < 0.001). Cox analysis confirmed PAD as an independent predictor of time to amputation (HR 2.65, 95% CI 1.75-4.00, p < 0.001). Revascularization was attempted in 280 limbs: 173 endovascular (61.8%), 75 open (26.8%), and 32 diagnostic-only (11.4%). Major amputation occurred in 16.2%, 22.7%, and 28.1%, respectively, without statistical significance (p = 0.199). On multivariable regression, PAD (OR 2.25, 95% CI 1.40-3.60, p < 0.001), dialysis-dependent ESRD (OR 3.53, 95% CI 1.99-6.26, p < 0.001), thrombophilia (OR 2.42, 95% CI 1.08-5.43, p = 0.033), and cerebrovascular disease (OR 1.79, 95% CI 1.03-3.14, p = 0.041) were independently associated with major amputation. The limb-level GEE model confirmed these findings: PAD (p = 0.004), dialysis-dependent ESRD (p < 0.001), and thrombophilia (p = 0.016) remained significant. Other covariates, including age, coronary disease, hypertension, smoking, and revascularization, were not found to be significant.
ConclusionPeripheral arterial disease significantly increases the risk of major amputation following a minor foot amputation. Dialysis dependence, thrombophilia, and cerebrovascular disease further contribute to this heightened risk. Notably, the specific method of revascularization performed did not impact the outcomes. These findings emphasize the paramount importance of assessing PAD status and comorbidity profile during patient counseling and may aid in identifying patients who would benefit from a primary major amputation.
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