Southern Association for Vascular Surgery
SAVS Home SAVS Home Past & Future Meetings Past & Future Meetings

Back to 2023 Abstracts

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 studentís 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.

Total Patients 509273236
Revas 30 days (%)Yes155 (30.5%)84 (30.8%)71 (30.1%)0.87
No354 (69.5%)189 (69.2%)165 (69.9%)
Endo 30 days (%)Yes104 (67.1%)54 (64.3%)50 (70.4%)0.48
No51 (32.9%)30 (35.7%)21 (29.6%)
Revas 30-90 days (%)Yes115 (22.6%)62 (22.7%)53 (22.5%)0.95
No394 (77.4%)211 (77.3%)183 (77.5%)
Endo 30-90 days (%)Yes74 (64.3%)41 (66.1%)33 (62.3%)0.58
No41 (35.7%)21 (33.9%)21 (37.7%)
Revas 90 days-1yr (%)Yes99 (19.4%)59 (21.6%)40 (16.9%)0.19
No410 (80.6%)214 (78.4%)196 (83.1%)
Endo 90 days-1yr (%)Yes57 (57.6%)30 (50.8%)27 (67.5%)0.1
No42 (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
VariablesAdjusted OR95% CIP value
Age1.0(1.0, 1.1)0.051
Sex: MaleRefRefRef
Sex: Female0.97(0.56, 1.7)0.91
Race: BlackRefRefRef
Race: White0.98(0.54, 1.8)0.95
Race: Other0.61(0.084, 4.4)0.62
Insurance: MedicareRefRefRef
Insurance: Medicaid0.81(0.39, 1.7)0.59
Insurance: Private1.9(0.65, 5.7)0.24
Insurance: Self Pay0.69(0.091, 5.3)0.72
Income: Q1RefRefRef
Income: Q21.20(0.66, 2.2)0.55
Income: Q31.02(0.47, 2.2)0.97
Income: Q40.46(0.11, 1.9)0.28
HTN1.0(0.49, 2.2)0.93
HDL1.5(0.85, 2.6)0.16
DM1.2(0.69, 2.2)0.48
ESRD2.1(1.2, 4.0)0.013
CAD1.0(0.58, 1.7)0.99
Smoker1.2(0.71, 2.2)0.44
Amputation: AKARefRefRef
Amputation: BKA0.72(0.42, 1.2)0.22
Amputation: TKD0.87(0.093, 8.2)0.91
Pre-Limb SalvageRefRefRef
Post-Limb Salvage0.090(0.049, 0.17)<0.001

Back to 2023 Abstracts