Gabel Joshua, Jabo Brice, Patel Sheela, Kiang Sharon, Bianchi Christian, Chiriano Jason, Teruya Theodore, Abou-Zamzam Ahmed M
Division of Vascular Surgery, Department of Cardiovascular and Thoracic Surgery, Loma Linda University, Loma Linda, CA.
Research Consulting Group, Center for Health Research, Loma Linda University, Loma Linda, CA.
Ann Vasc Surg. 2018 Jan;46:75-82. doi: 10.1016/j.avsg.2017.07.034. Epub 2017 Sep 6.
Despite an aggressive climate of limb salvage and revascularization, 7% of patients with peripheral artery disease undergo major lower extremity amputation (LEA). The purpose of this study was to describe the current demographics and early outcomes of patients undergoing major LEA in the Vascular Quality Initiative (VQI).
The VQI amputation registry was reviewed to identify patients who underwent major LEAs. Patient factors, limb characteristics, procedure type, and intraoperative variables were analyzed by the level of amputation. Factors associated with amputation level, 30-day complications, and mortality were analyzed using chi-squared analysis for significance with associated P values. Propensity score adjustment was used to balance statistically significant differences observed in subject characteristics by amputation level for the associated relative risk of a given outcome.
Between 2013 and 2015, 2,939 major LEAs were recorded in the VQI amputation registry. The ratio of below-knee to above-knee amputation (BKA:AKA) was 1.29:1. The mean age was 66 years, 64% were male, 84% lived at home before admission, and 68% were ambulatory. Comorbidities included diabetes (67%), coronary artery disease (32%), end-stage renal disease (22%), and chronic obstructive pulmonary disease (23%). The mean preoperative ankle-brachial index (ABI) was 0.78. Overall, 43% had a history of prior ipsilateral revascularization. Indications for amputation were ischemic rest pain or tissue loss (58%), uncontrolled infection (31%), acute ischemia (9%), and neuropathic tissue loss (2%). The overall perioperative complication rate was 15%, 25% were discharged home, and the 30-day mortality was 5%. Patients who received an AKA versus BKA were more likely to be female (40.61% vs. 31.70%), more than age 70 (48.79% vs. 32.55%), underweight (18.63% vs. 9.18%), nonambulatory (40.22% vs. 25.18%), have an ABI <0.6 (58.00% vs. 45.26%), and carry nonprivate insurance (77.40% vs. 69.08%) (all P < 0.001). Patients undergoing AKA were less likely to have 30-day postoperative complications (12.24% vs. 17.87%) but had higher 30-day mortality (6.70% vs. 3.09%) than BKA patients (all P < 0.001).
In the VQI registry, major LEA was performed predominantly for ischemic rest pain and tissue loss with a BKA:AKA ratio of 1.29:1. Patients undergoing AKA versus BKA were older, had lower ABI, lower rates of 30-day postoperative complications but higher rates of 30-day mortality. This registry offers an important real-world resource for studies pertaining to vascular surgery patients undergoing major lower extremity amputation.
尽管当前保肢和血管重建的形势积极，但仍有7%的外周动脉疾病患者接受了下肢大截肢术（LEA）。本研究的目的是描述血管质量改进计划（VQI）中接受下肢大截肢术患者的当前人口统计学特征和早期结局。
回顾VQI截肢登记处的数据，以确定接受下肢大截肢术的患者。根据截肢水平分析患者因素、肢体特征、手术类型和术中变量。使用卡方分析评估与截肢水平、30天并发症和死亡率相关的因素，得出具有统计学意义的P值。采用倾向评分调整来平衡因截肢水平不同而在受试者特征中观察到的统计学显著差异，以确定给定结局的相关相对风险。
2013年至2015年期间，VQI截肢登记处记录了2939例下肢大截肢术。膝下截肢与膝上截肢的比例（BKA:AKA）为1.29:1。患者的平均年龄为66岁，64%为男性，84%在入院前居住在家中，68%能够行走。合并症包括糖尿病（67%）、冠状动脉疾病（32%）、终末期肾病（22%）和慢性阻塞性肺疾病（23%）。术前踝肱指数（ABI）的平均值为0.78。总体而言，43%的患者有同侧血管重建史。截肢的指征为缺血性静息痛或组织缺损（58%）、无法控制的感染（31%）、急性缺血（9%）和神经性组织缺损（2%）。围手术期总体并发症发生率为15%，25%的患者出院回家，30天死亡率为5%。接受膝上截肢术的患者比接受膝下截肢术的患者更可能为女性（40.61%对31.70%）、年龄超过70岁（48.79%对32.55%）、体重过轻（18.63%对9.18%）、无法行走（40.22%对25.18%）、ABI<0.6（58.00%对45.26%）以及拥有非私人保险（77.40%对69.08%）（所有P<0.001）。接受膝上截肢术的患者术后30天并发症的发生率较低（12.24%对17.87%），但30天死亡率高于接受膝下截肢术的患者（6.70%对3.09%）（所有P<0.001）。
在VQI登记处，下肢大截肢术主要用于治疗缺血性静息痛和组织缺损，BKA:AKA比例为1.29:1。接受膝上截肢术与膝下截肢术的患者年龄更大，ABI更低，术后30天并发症发生率更低，但30天死亡率更高。该登记处为有关接受下肢大截肢术的血管外科患者的研究提供了重要的真实世界资源。
