Predictors of major amputation despite patent bypass grafts

Abstract

Whereas a patent vein graft is important to all vascular surgeons, additional factors should be considered in trying to attain limb salvage for patients with CLI. These factors include intervening surgically before CLI has progressed to a state of gangrene or limited activity and optimizing nutrition, diabetes control, cardiac conditions, and activity level. Revision offers hope for clinical improvement but may be delayed when there is no graft lesion identified. The absence of a graft lesion to revise may also portend amputation despite a patent graft because of nongraft-related factors such as infection. Finally, the experience of a severe (vs mild) adverse event may also result in limb loss despite a patent graft. Systematic efforts to reduce severe adverse events among patients may also lead to increased limb salvage.

Contemporary (2009-2014) clinical outcomes after femoropopliteal bypass surgery for chronic limb threatening ischemia are inferior to those reported in the UK Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL) trial (1999-2004)

“…Further research is required to determine if the CS data reported here are generalizable to current vascular surgical practice and, if so, to determine the reasons for these unexpected data. Possible causes include a loss of surgical skills as a result of the overall reduction in open vascular procedures and/or a tendency to reserve BS for patients considered unsuitable for endovascular intervention due the severity of their tissue loss and/or the extent and complexity of their underlying disease [12][13][14][15] . While loss of surgical skills is certainly possible, this does not appear to be supported by the observation that CS patients had lower overall 30-day mortality and morbidity as well as a trend towards a shorter index admission [16][17][18][19] .…”

Infrainguinal open reconstruction: a review of surgical considerations and expected outcomes

“…Overall, 1-year postoperative freedom from major amputation and amputation-free survival has been reported as 87% and 76%, respectively 63. Despite patent bypass grafts, some patients do not achieve limb salvage, and studies have demonstrated similar 1-year amputation rates in patients with patent (6.3%) and occluded (5.7%) grafts 64. Thus, identification of patient comorbidities contributing to amputation in patent grafts in addition to prevention of graft failure is essential in limiting limb loss.…”

“…Thus, identification of patient comorbidities contributing to amputation in patent grafts in addition to prevention of graft failure is essential in limiting limb loss. Patients with diabetes, end-stage renal disease, previous amputations, peripheral neuropathy, preoperative gangrene, postoperative SSI, and abnormal wound healing are at an elevated risk for amputation 64,65. For this cohort, management of the underlying conditions is vital to improved outcomes postoperatively.…”

Healthcare Disparities in Dysvascular Lower Extremity Amputations

“…Asians with PAD have been found to have both increased and decreased risk compared with Whites, which may be due to how they are grouped (with or without Pacific Islanders) [54,58]. Others have looked at the risk of amputation following LER procedures and found that when Black and Hispanic patients do receive LER, they continue to have an increased risk, compared with Whites, of requiring reintervention and LEA within the next 12 months [49,61,[64][65][66]. There is some evidence that the disparities in amputation-free survival, after an LER, have been widening between Blacks and Whites with PAD [64].…”