University of California Davis School of Medicine, Department of Surgery, Division of Vascular Surgery, Sacramento, CA.
University of California Davis School of Medicine, Department of Surgery, Division of Trauma, Acute Care surgery, and Surgical Critical Care, Sacramento, CA.
Ann Vasc Surg. 2021 Oct;76:211-217. doi: 10.1016/j.avsg.2021.07.003. Epub 2021 Aug 14.
Advanced peripheral arterial disease is associated with an overall annual mortality between 20-40%. Amputees are at particularly high risk for perioperative and long-term mortality and may benefit from palliative care programs to improve quality of life and to align medical treatments with their goals of care. As studies of palliative care in vascular patients are scarce, we sought to examine palliative care utilization using below knee amputation (BKA) as a surrogate for advanced peripheral arterial disease.
All patients who underwent below knee amputation over a 5-year period at a single large academic medical center were identified through chart review. Demographics, preoperative conditions, intraoperative factors, and perioperative outcomes were recorded. The primary outcome was palliative care consultation at the time of the amputation. The secondary outcomes included one-year mortality and palliative care consultation prior to death.
The cohort comprised 111 patients (76 men, 35 women) who received BKA for chronic limb threatening ischemia. Three patients (2.7%) received palliative care consultations at the time of their amputation. Of these, one had been obtained remotely for an oncologic condition and the others for surgical decision-making. Follow-up was available for 73 patients. One-year mortality was 21.9% (n = 16) at a mean of 102 ± 86 days after BKA. Among patients who died within 1 year of their amputation, 37.5% (n = 6) received palliative care consultations prior to their death. The median interval between amputation and palliative consultation was 26 (IQR 14-81) days. The median interval between palliative consultation and death was 9 (IQR 4-39) days.
Palliative care services were rarely provided to patients with advanced peripheral arterial disease. When obtained, consultations occurred closer to death than to amputation suggesting a missed opportunity to receive the benefits of early evaluation. Future studies can be aimed at identifying a cohort of vascular patients who would most benefit from early palliative evaluation and determining if palliative consultations alter health care utilization patterns and outcomes for vascular patients.
晚期外周动脉疾病的年总死亡率在 20%至 40%之间。截肢患者的围手术期和长期死亡率特别高，可能受益于姑息治疗方案，以提高生活质量，并使医疗治疗与他们的护理目标保持一致。由于血管患者的姑息治疗研究很少，我们试图通过以下肢截肢（BKA）作为晚期外周动脉疾病的替代指标来检查姑息治疗的使用情况。
通过病历回顾，确定了在一家大型学术医疗中心接受下肢截肢手术的所有患者。记录了患者的人口统计学、术前情况、手术期间的因素和围手术期结果。主要结果是截肢时的姑息治疗咨询。次要结果包括一年内的死亡率和死亡前的姑息治疗咨询。
该队列包括 111 名患者（76 名男性，35 名女性），因慢性肢体威胁性缺血接受 BKA。有 3 名患者（2.7%）在截肢时接受了姑息治疗咨询。其中 1 例是为了肿瘤疾病而远程获得的，其他 2 例是为了手术决策。有 73 名患者的随访资料。截肢后 1 年内的死亡率为 21.9%（n=16），平均为 102±86 天。在 1 年内死亡的患者中，有 37.5%（n=6）在死亡前接受了姑息治疗咨询。截肢和姑息治疗咨询之间的中位数间隔为 26（IQR 14-81）天。姑息治疗咨询和死亡之间的中位数间隔为 9（IQR 4-39）天。
姑息治疗服务很少提供给晚期外周动脉疾病患者。当获得姑息治疗服务时，咨询时间更接近死亡，而不是接近截肢，这表明错过了早期评估的机会。未来的研究可以针对一组最需要早期姑息评估的血管患者，确定姑息治疗咨询是否改变血管患者的医疗保健利用模式和结果。
