Shah Samir K, Xiang Lingwei, Adler Rachel R, Clark Clancy J, Hsu John, Mitchell Susan L, Finlayson Emily, Kim Dae Hyun, Lin Kueiyu Joshua, Weissman Joel S
Division of Vascular Surgery, University of Florida, Gainesville, FL.
Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
J Vasc Surg. 2025 Jan;81(1):191-199.e22. doi: 10.1016/j.jvs.2024.08.058. Epub 2024 Sep 1.
Major lower limb amputation is a disfiguring operation associated with impaired mobility and high near-term mortality. Informed decision-making regarding amputation requires outcomes data. Despite the co-occurrence of both chronic limb-threatening ischemia (CLTI) and Alzheimer's disease and related dementias (ADRD), there is sparse data on the outcomes of major limb amputation in this population and the impact of frailty. We sought to determine mortality, complications, readmissions, revisions, intensive interventions (eg, cardiopulmonary resuscitation), and other outcomes after amputation for CLTI in patients living with ADRD looking at the modifying effects of frailty.
We examined Medicare fee-for-service claims data from January 1, 2016, to December 31, 2020. Patients with CLTI undergoing amputation at or proximal to the ankle were included. Along with demographic information, dementia status, and comorbid conditions, we measured frailty using a claims-based frailty index. We dichotomized dementia and frailty (pre-frail/robust = "non-frail" vs moderate/severe frailty = "frail") to create four groups: non-frail/non-ADRD, frail/non-ADRD, non-frail/ADRD, and frail/ADRD. We used linear and logistic regression via generalized estimating equations in addition to performing selected outcomes analyses with death as a competing risk to understand the association between dementia status, frailty status, and 1-year mortality as our primary outcome in addition to the postoperative outcomes outlined above.
Among 46,930 patients undergoing major limb amputation, 11,465 (24.4%) had ADRD and 24,790 (52.8%) had frailty. Overall, 55.9% of amputations were below-knee. Selected outcomes among frail/ADRD patients undergoing amputation (n = 10,153) were: 55.3% 1-year mortality 29.6% readmissions at 30 days, and 32.3% amputation revision/reoperation within 1 year. Of all four groups, those in the frail/ADRD had the worst outcomes only for 1-year mortality.
First, patients with ADRD or moderate/severe frailty suffer an array of very poor outcomes after major limb amputation for CLTI, including high mortality, readmissions, revision, and risks of discharge to higher levels of care. Second, there is a complex relationship between outcome severity and ADRD/frailty status. Specifically, frailty is more often than ADRD associated with the poorest results for any given outcome. These data provide important outcomes data to help align decision-making with health care values and goals.
下肢大截肢是一种会导致身体残疾的手术，与行动能力受损及近期高死亡率相关。关于截肢的明智决策需要有预后数据。尽管慢性肢体威胁性缺血（CLTI）与阿尔茨海默病及相关痴呆症（ADRD）常同时出现，但关于该人群大肢体截肢的预后以及虚弱的影响的数据却很稀少。我们试图确定患有ADRD的CLTI患者截肢后的死亡率、并发症、再入院率、翻修手术、强化干预措施（如心肺复苏）及其他预后情况，并观察虚弱的调节作用。
我们研究了2016年1月1日至2020年12月31日期间医疗保险按服务收费的索赔数据。纳入在踝关节或其近端进行截肢的CLTI患者。除了人口统计学信息、痴呆状态和合并症外，我们使用基于索赔的虚弱指数来衡量虚弱程度。我们将痴呆和虚弱情况进行二分法分类（虚弱前期/强壮 = “非虚弱” 与中度/重度虚弱 = “虚弱”），以创建四组：非虚弱/非ADRD、虚弱/非ADRD、非虚弱/ADRD和虚弱/ADRD。除了以死亡作为竞争风险进行选定的预后分析以了解痴呆状态、虚弱状态与1年死亡率之间的关联外，我们还通过广义估计方程使用线性和逻辑回归来分析上述术后预后情况。
在接受大肢体截肢的46,930名患者中，11,465名（24.4%）患有ADRD，24,790名（52.8%）存在虚弱情况。总体而言，55.9%的截肢手术为膝下截肢。接受截肢的虚弱/ADRD患者（n = 10,153）的选定预后情况如下：一年死亡率为55.3%，30天内再入院率为29.6%，1年内截肢翻修/再次手术率为32.3%。在所有四组中，虚弱/ADRD组仅在1年死亡率方面预后最差。
第一，患有ADRD或中度/重度虚弱的患者在因CLTI进行大肢体截肢后会出现一系列非常差的预后情况，包括高死亡率、再入院率、翻修手术以及转至更高护理水平机构的风险。第二，预后严重程度与ADRD/虚弱状态之间存在复杂关系。具体而言，对于任何给定的预后情况，虚弱比ADRD更常与最差结果相关。这些数据提供了重要的预后数据，有助于使决策与医疗保健价值观和目标保持一致。
