Low Risk of Procedure Related Major Amputation Following Revascularisation for Intermittent Claudication: A Population Based Study

Abstract

WHAT THIS PAPER ADDSThe procedure-related amputation rate is insufficiently investigated. Revascularization for intermittent claudication confers a low but existing risk of procedure related major amputation within the first post-procedural year.Objective: To investigate the risk of procedure-related major amputation attributable to revascularization for intermittent claudication (IC) in a population-based observational cohort study. Methods: All patients who underwent open or endovascular lower limb revascularisation for IC in Sweden between 12 May 2008 and 31 December 2012 were identified from the Swedish National Quality Registry for Vascular Surgery (Swedvasc) and data on above ankle amputations were extracted from the National Patient Registry. Any uncertainty regarding amputation level and laterality was resolved by reviewing medical charts. For the final analysis, complete medical records of all patients with IC, having ipsilateral amputation after the revascularisation procedure, were reviewed. Patients wrongly classified as having IC were excluded. Ipsilateral amputations within one year of the revascularisation were defined as procedure related. Results: Altogether, 5 860 patients revascularised for IC were identified of whom 109 were registered to have undergone a post-operative ipsilateral lower limb amputation during a median follow up of 3.9 years (standard deviation 1.5 y). Seventeen were duplicate registrations and 51 were patients with chronic limb threatening ischaemia, misclassified as IC in the registry. One patient had not undergone any revascularisation, one was revascularised for a popliteal artery aneurysm, one was revascularised for acute limb ischaemia, one had a minor amputation only, and one patient was not amputated at all. Twenty-seven were amputated more than one year after the procedure. Thus, the major amputation rate within one year of revascularisation for IC was 0.2% (n ¼ 9/5 860). Conclusion: Revascularisation for IC in a contemporary setting confers a low but existing risk of procedure related major amputation within the first post-procedural year.

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

“…However, historical data illustrate that the risk of amputation in patients with IC remains quite low 2 . A recent, population-based study estimated yearly risk of major amputation at 0.2%, consistent with the estimates in our study 34 . Although revascularization, either by endovascular or surgical means, can improve IC symptoms, suboptimal technical outcomes, and intervention failure can lead to reinterventions and clinical deterioration, negatively altering the clinical course of IC 15 .…”

“…2 A recent, populationbased study estimated yearly risk of major amputation at 0.2%, consistent with the estimates in our study. 34 Although revascularization, either by endovascular or surgical means, can improve IC symptoms, suboptimal technical outcomes, and intervention failure can lead to reinterventions and clinical deterioration, negatively altering the clinical course of IC. 15 Indeed, the current meta-analysis confirmed significantly more revascularizations are performed once invasive treatments are initiated.…”

Diabetes mellitus was not associated with lower amputation-free survival after open revascularization for chronic limb-threatening ischemia – A nationwide propensity score adjusted analysis

“…21 Swedvasc has not yet been validated for procedures related to PAD, but Djerf et al found that almost half of patients registered in Swedvasc due to major amputation following intermittent claudication in fact had CLTI. 38 Therefore, the risk of misclassification of CLTI as intermittent claudication was probably low in the present study. It cannot be ruled out, however, that some patients were reclassified as having CLTI if the surgery for intermittent claudication failed.…”

Worse cardiovascular prognosis after endovascular surgery for intermittent claudication caused by infrainguinal atherosclerotic disease in patients with diabetes

“…It would also have been desirable to analyse precise location and extent of the atherosclerotic lesions according to the Trans-Atlantic Inter-Society Consensus II classification, 30 as previous studies have implicated a correlation between lesion extent and risk of amputation. 10 Due to the risk of misclassification of CLTI as IC 31 and uncertainty of amputation data in patient registries, the reported association between diabetes and increased risk of major amputation should be interpreted very cautiously. Unfortunately, we did not have ethical permission to validate amputation data in individual patient files at different centres.…”