Division of Vascular Surgery, University of California, Davis Medical Center, Sacramento, Calif.
Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, Calif.
J Vasc Surg. 2020 Jul;72(1):268-275. doi: 10.1016/j.jvs.2019.10.063. Epub 2020 Jan 21.
Studies evaluating major amputation after initial minor amputation are few with rates of subsequent major amputation ranging from 14% to 35% with limited understanding of associated comorbidities and time to limb loss. The aim of this study is to determine the major amputation rates for patients who had already undergone an initial minor amputation and determine which factors are associated with the need for subsequent major amputation.
Using statewide data between 2005 and 2013, patients with peripheral artery disease (PAD), diabetes mellitus (DM), and combined PAD/DM who had a lower extremity ulcer and who had also undergone a minor amputation were identified. These patients were evaluated for the rate of subsequent major amputation and competing risk Cox proportional hazards modeling was used to study which factors were associated with the risk of subsequent limb loss.
The cohort consisted of 11,597 patients (DM, n = 4254; PAD, n = 2142; PAD/DM, n = 5201) with lower extremity ulcers who underwent an initial minor amputation. The rate of any subsequent amputation was highest in patients with PAD/DM (23% vs DM = 17%, PAD = 17%; P = not statistically significant). The rate of subsequent minor amputation was 16% in the PAD/DM versus 15.2% in PAD and 12.2% in patients with DM (P < .001). Patients with PAD/DM had the highest rate of subsequent major amputation (6.3% vs DM = 5.2%, PAD = 2.1%; P < .001). There was no statistically significant difference in the median time to major amputation among the three groups (PAD/DM, 13 months; DM, 14 months; PAD, 8.6 months; P = NS). Patients who were revascularized before a repeat minor amputation had a decreased risk of a major amputation compared with those who were intervened on after a repeat minor amputation (hazard ratio, 0.002; 95% confidence interval, 0-0.22). Patients treated completely in the outpatient setting were also less likely to undergo subsequent major amputation (hazard ratio, 0.7; 95% confidence interval, 0.5-0.98) compared with those who required hospitalization or presented to the emergency room.
Patients with ulcers and combined PAD and DM have a higher risk for secondary major and minor amputation than patients with either disease alone with half of the limb loss occurring at approximately 1 year after the initial minor amputation. Additionally, early diagnosis and appropriate referral may result in decreased limb loss for these patients.
评估初次小截肢后发生主要截肢的研究较少，随后主要截肢的发生率为 14%至 35%，对相关合并症和肢体丧失时间的了解有限。本研究旨在确定已接受初次小截肢的患者的主要截肢率，并确定哪些因素与随后需要进行主要截肢有关。
使用 2005 年至 2013 年期间的全州数据，确定患有外周动脉疾病（PAD）、糖尿病（DM）和合并 PAD/DM 且下肢溃疡并已接受小截肢的患者。评估这些患者随后发生主要截肢的比率，并使用竞争风险 Cox 比例风险模型研究哪些因素与随后的肢体丧失风险相关。
该队列包括 11597 名患有下肢溃疡并接受初次小截肢的患者（DM，n=4254；PAD，n=2142；PAD/DM，n=5201）。在 PAD/DM 患者中，任何后续截肢的发生率最高（23% vs DM=17%，PAD=17%；P=无统计学意义）。PAD/DM 患者的后续小截肢率为 16%，PAD 为 15.2%，DM 为 12.2%（P<0.001）。PAD/DM 患者随后发生主要截肢的比率最高（6.3% vs DM=5.2%，PAD=2.1%；P<0.001）。三组之间主要截肢的中位时间无统计学差异（PAD/DM，13 个月；DM，14 个月；PAD，8.6 个月；P=NS）。与在重复小截肢后接受干预的患者相比，在重复小截肢前接受血运重建的患者发生主要截肢的风险降低（风险比，0.002；95%置信区间，0-0.22）。与需要住院或到急诊室就诊的患者相比，完全在门诊治疗的患者随后发生主要截肢的可能性也较小（风险比，0.7；95%置信区间，0.5-0.98）。
患有溃疡和合并 PAD 和 DM 的患者发生继发性主要和小截肢的风险高于仅患有其中一种疾病的患者，大约一半的肢体丧失发生在初次小截肢后约 1 年。此外，早期诊断和适当转诊可能会减少这些患者的肢体丧失。
