SHORT AND LONG TERM MORTALITY RATES AFTER MAJOR LOWER LIMB AMPUTATION IN PATIENTS OLDER THAN 80 YEARS

  • Juliana Varino Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Carolina Mendes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • André Marinho Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Roger Rodrigues Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Bárbara Pereira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Mário Moreira Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Mafalda Correia Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Luís Antunes Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Anabela Gonçalves Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Óscar Gonçalves Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Albuquerque Matos Serviço de Angiologia e Cirurgia Vascular, Centro Hospitalar e Universitário de Coimbra
  • Margarida Marques Departamento de Tecnologia e Sistemas de Informação, Centro Hospitalar e Universitário de Coimbra ; Laboratório de Bioestatística e Informática Médica, Faculdade de Medicina, Centro Hospitalar e Universitário de Coimbra
Keywords: Amputation, mortality, diabetic foot, peripheral arterial disease

Abstract

Introduction: Mortality rates after lower limb amputation are notoriously high and age is associated with increased mortality. The aim of this retrospective study was to determine mortality rates after a first major lower limb amputation in a cohort of patients older 80 years old.

Methods: We performed an analysis of factors affecting early and late outcome after major lower limb amputation for peripheral vascular disease or diabetic complications at a tertiary referral vascular center between 2008 and 2015 in patients older than 80 years old.

Results: 557 patients underwent a major amputation (54% female), of median age 86.3 ± 4.4 years and 20% had bilateral amputations during the study period. Median follow-up was 4.8 [0.8; 16.4] months. 30-day and 2-year mortality rates were 27% and 77%. Age adjusted 1-year mortality rate after trans-femoral amputation (TFA) was 68%, almost double that of trans-tibial amputation (TTA) (36%, p= .04). The rate of re-operation was substantially greater after TTA (36% vs 17%, p< .01). Survival and Cox regression analysis demonstrated that long-term mortality was associated with hospital re-admission (HR: 2.00, p <.05) cerebrovascular and chronic kidney disease (HR: 1.22 and 1.24 respectively, p <.05), acute ischemic amputation (HR 1.21 p <.05). Previous revascularized amputees and TTA survived longer (HR 0.65 and 0.51 respectively, p <.01).

Conclusions: This study adds prognostic information for a well-defined population of people with a first amputation at or proximal to a transtibial level, due to a vascular or a infection related cause. Mortality rates after lower limb amputation are notoriously high, with only 23% of these cohort patients living longer than two years.

References

1. Remes L., Isoaho R., Vahlberg T., et al; Major lower extremity amputation in elderly patients with peripheral arterial disease:
incidence and survival rates; Aging Clin Exp Res, 20 (5) (2008), pp. 385–393; DOI: 10.1007/BF03325142.

2. Scott S.W., Bowrey S., Clarke D. et al; Factors influencing shortand long-term mortality after lower limb amputation. Anaesthesia.
2014;69:249–258.

3. Icks, A., Scheer, M., Morbach, S. et al; Time-dependent impact of diabetes on mortality in patients after major lower extremity
amputation: survival in a population-based 5-year cohort in Germany. Diabetes Care. 2011;34:1350–1354. http://dx.doi.org/10.2337/dc10-2341

4. Gasdete Correia L.C., Boavida J.M., Fragoso de Almeida J.P.; Relatório Anual do Observatório Nacional da Diabetes- “Diabetes: Factos
e Números 2014”; Lisboa; 2015, 7th edition. Available at: www.spd.pt / diabetes@spd.pt / observatorio@spd.pt.

5. Rolim D., Sampaio S., Gonçalves-Dias P. et al; Mortality after amputation; Angiologia e Cirurgia Vascular. 2015; 11(3):166-170;
doi:10.1016/j.ancv.2015.06.001

6. Fortington, L.V., Geertzen, J.H., van Netten, J.J. et al; Short and long term mortality rates after a lower limb amputation.
Eur J Vasc Endovasc Surg. 2013;46:124–131. doi:10.1016/j.ejvs.2013.03.024

7. Hasanadka R., Mclafferty R.B., Moore C.J. et al; Predictors of wound complications following major amputation for critical limb
ischemia; J Vasc Surg 2011; 54:1374-82.

8. Schuyler Jones W. Patel M.R., Dai D. et al; High mortality risks after major lower extremity amputation in Medicare patients with peripheral
artery disease; American heart journal, 2013;165(5):809-815; DOI: 10.1016/j.ahj.2012.12.002

9. Rose N, Gigi R., Haim A. et al; Mortality and re-operations following lower limb amputations; IMAJ 2014; 16:83-87.
10. Van Netten, J.J., Fortington, L.V., Hinchliffe, et al; Early post-operative mortality after major lower limb amputation: a systematic
review of population and regional based studies. Eur J Vasc Endovasc Surg. 2016;51:248–257.

11. Davenport D.L., Ritchie J.D., Xenos E.S.; Incidence and risk factors for 30-day postdischarge mortality in patients with vascular
disease undergoing major lower extremity amputation; Ann Vasc Surg, 26 (2) (2012), pp. 219–224.

12. Thorud J.C.T.; Plemmons B.; Buckley C.J. et al; Mortality after nontraumatic major amputation among patients with diabetes
and peripheral vascular disease: a systematic review; the journal of foot and ankle surgery; 55(2016)591:599. doi:10.1053/j.jfas.2016.01.012

13. Nelson M.T., Greenblatt D.Y., Soma G. et al; Preoperative factors predict mortality after major lower-extremity amputation;
Surgery, Volume 152, Issue 4, October 2012, Pages 685–696.

14. Flagia E., Clericia G., Caminti M. et al; Mortality after major amputation in diabetic with critical limb ischemia who did and did
not undergo previous peripheral revascularization: data of acohort study of 564 consecutive diabetic patients; J Diabetes
Complications. 2010 Jul-Aug;24(4):265-9. doi:10.1016/j.jdiacomp.2009.02.004.

15. Feinglass J., Pearce W.H., Martin G.J., et al; Postoperative and late survival outcomes after major amputation: findings from the
Department of Veterans Affairs National Surgical Quality Improvement Program; Surgery, 130 (2001), pp. 21–29.

16. Kristensen M.T., Holm G., Kirketerp-Moller K. et al; Very low survival rates after non-traumatic lower limb amputation in a consecutive
series: what to do? Interact Cardiovasc Thorac Surg 2012; 14(5): 543–7; doi:10.1093/icvts/ivr075.

17. M: Inderbitzi, R., Buettiker, M., Enzler, M.; The long-term mobility and mortality of patients with peripheral arterial disease following
bilateral amputation. Eur J Vasc Endovasc Surg. 2003;26:59–64.
Published
2017-11-12
Section
Original Article

Most read articles by the same author(s)