Criteria for reliable selection of the lowest level of amputation in peripheral vascular disease

To improve the chances for the amputee to become ambulatory the most distal level of amputation should be selected in patients with end-stage peripheral vascular disease. Physical examination alone provides insufficient information when amputation levels are closely related to areas with signs and symptoms of ischemia. In the present series of 85 lower extremity amputations the predictive values of clinical parameters and skin perfusion pressure measurements are assessed. The role of clinical judgment is clarified: the most distal level of amputation is to be selected by physical examination, but further information is required to assess the healing potential at the selected level. The presence of palpable pulses immediately above the selected level correlates well with primary wound healing (p less than 0.001, negative predictive value 100%). The absence of palpable pulses and angiographic patency scores are of no clinical value in amputation level selection. Skin perfusion pressure measurements were of excellent predictive value (p less than 0.001, positive predictive value 89%, negative predictive value 99%). According to these data a strategy is proposed for routine determination of the lowest level of amputation, where primary wound healing can be expected.