Shah Samir K, Bena James F, Allemang Matthew T, Kelso Rebecca, Clair Daniel G, Vargas Lina, Kashyap Vikram S
1Department of Vascular Surgery, Cleveland Clinic, Cleveland, OH, USA.
Vasc Endovascular Surg. 2013 Nov;47(8):608-13. doi: 10.1177/1538574413503715. Epub 2013 Sep 4.
Tissue loss or gangrene in the setting of lower extremity peripheral artery disease (PAD) may result in amputation. Previous studies have demonstrated elevated mortality rates after major transtibial and transfemoral amputation. Also, amputation of 1 leg may be associated with subsequent major amputation of the contralateral leg. The aim of our study was to identify patient variables associated with mortality and contralateral amputation.
We reviewed the medical records of patients who underwent transfemoral or transtibial amputation secondary to PAD from 2004 to 2009. A total of 454 consecutive major amputations were performed on 391 patients, with 63 of these having a subsequent contralateral amputation. Standard demographic information, comorbidities, prior vascular interventions, and relevant procedural information were extracted from patient records. Kaplan-Meier estimates of survival were calculated. Cox proportional hazard models were used to estimate the risk of death and contralateral amputation. Multivariate Cox proportional hazards models were fit for all variables shown to be marginally associated in the univariate model.
In 391 amputees, the mean age was 67.3 years, 63% were male and 62% were caucasian. Patients had high rates of diabetes (63%), hypertension (83%), renal insufficiency (35%), hyperlipidemia (51%), and prior ipsilateral vascular intervention (75%). Seventy percent of patients had below-knee amputations. Perioperative mortality was 9.2% (n = 36). Survival at 12 and 24 months was 70% (95% confidence interval [CI], 65%-74%) and 60% (95% CI, 55%-65%), respectively. Multivariate analysis demonstrated that several independent factors were detrimental to survival including chronic obstructive pulmonary disease (hazard ratio [HR] 1.82, P = .002), dialysis dependence (HR 2.50, P < .001), high cardiac risk (HR 2.20, P < .001), and guillotine amputation (HR 2.49, P = .004). Dialysis (HR 2.42, P = .002) and revision of the index ipsilateral amputation to a higher level (HR 2.02, P = .014) were associated with a subsequent contralateral amputation.
Patients with advanced PAD that require lower extremity amputation have diminished survival and significant contralateral amputation rates. Elderly patients on dialysis are particularly prone to dying or losing the other leg after a major amputation. These data support strategies to enhance limb preservation and optimize medical comorbidities in these patients.
下肢外周动脉疾病（PAD）导致的组织缺失或坏疽可能会引发截肢。既往研究表明，经胫骨干和经股截肢后的死亡率会升高。此外，一侧下肢截肢可能与对侧下肢随后的大截肢相关。我们研究的目的是确定与死亡率和对侧截肢相关的患者变量。
我们回顾了2004年至2009年因PAD接受经股或经胫截肢患者的病历。对391例患者共进行了454次连续的大截肢手术，其中63例随后进行了对侧截肢。从患者记录中提取了标准的人口统计学信息、合并症、既往血管干预措施以及相关手术信息。计算了Kaplan-Meier生存估计值。使用Cox比例风险模型来估计死亡和对侧截肢的风险。对单变量模型中显示有微弱关联的所有变量拟合多变量Cox比例风险模型。
在391例截肢患者中，平均年龄为67.3岁，63%为男性，62%为白种人。患者糖尿病（63%）、高血压（83%）、肾功能不全（35%）、高脂血症（51%）以及既往同侧血管干预（75%）的发生率较高。70%的患者进行了膝下截肢。围手术期死亡率为9.2%（n = 36）。12个月和24个月时的生存率分别为70%（95%置信区间[CI]，65% - 74%）和60%（95% CI，55% - 65%）。多变量分析表明，几个独立因素对生存有害，包括慢性阻塞性肺疾病（风险比[HR] 1.82，P = .002）、透析依赖（HR 2.50，P < .001）、高心脏风险（HR 2.20，P < .001）以及断头台式截肢（HR 2.49，P = .004）。透析（HR 2.42，P = .002）以及将同侧初次截肢部位改为更高水平（HR 2.02，P = .014）与随后的对侧截肢相关。
需要进行下肢截肢的晚期PAD患者生存率降低且对侧截肢率较高。接受透析的老年患者在大截肢后尤其容易死亡或失去另一条腿。这些数据支持在这些患者中加强肢体保留和优化合并症的策略。
