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Influence of failed arterial reconstruction on the outcome of major limb amputation
P Stirnemann1, B Walpoth, H U Würsten
1Klinik für Thorax-Herz-, und Gefässchirurgie Inselspital, Berne, Switzerland.
Insights
Failed vascular repair worsens limb ischemia, increasing amputation levels and complicating wound healing. Secondary amputations after failed revascularization show poorer outcomes than primary amputations.
Area of Science:
- Vascular Surgery
- Limb Ischemia Management
- Amputation Outcomes
Background:
- Unsuccessful vascular repair can exacerbate pre-existing limb ischemia.
- This exacerbation increases the risk of subsequent revascularization procedures.
Purpose of the Study:
- To compare outcomes of primary major amputations versus secondary amputations following failed revascularization.
- To evaluate the impact of failed revascularization on amputation level and wound healing.
Main Methods:
- Retrospective analysis of 94 primary major amputations (Group A) and 112 secondary amputations (Group B).
- Patients presented with chronic critical limb ischemia (grades III and IV).
- Comparison of amputation levels, wound healing rates, and pre-operative risk factors.
Main Results:
- Secondary amputations (Group B) resulted in higher rates of above-knee amputation (30%) compared to primary amputations (Group A) (13%).
- Failed revascularization significantly decreased ankle systolic pressure index (0.27 to 0.13).
- Primary wound healing was achieved in 68% of Group A patients versus 39% in Group B.
Conclusions:
- Failed vascular reconstruction can worsen limb ischemia, leading to complications.
- Higher amputation levels and poor wound healing are associated with secondary amputations after failed revascularization.
- Vascular repair failure necessitates higher amputation levels and complicates healing.
Background:
Unsuccessful vascular repair may further preexisting limb ischemia and thus increase the risk of revascularization procedures.
Methods:
The results of 94 primary major amputations (group A) have been analyzed and compared with 112 secondary ablations (group B) carried out after failed revascularization efforts. All patients suffered from chronic critical ischemia (grades III and IV) of the lower extremities. In group A the severity of ischemic symptoms was more pronounced (trophic changes in 80% vs 66% in group B), and a preponderance for older age, diabetes mellitus, and incidence of cardiac failure and cerebrovascular insufficiency was evident.
Results:
In patients undergoing secondary amputation the final transection level was adversely affected by preceding unsuccessful reconstructive attempts. In spite of the better risk profile, 30% of patients in group B were subjected to above-knee amputation compared with 13% of patients in group A. The aggravated limb ischemia caused by graft failure is reflected by the decrease of the mean ankle systolic pressure index from 0.27 to 0.13 (before and after failed revascularization attempts). Although more amputations at the below-knee level were performed initially in group A, primary wound healing was obtained among these subjects in 68% of patients (compared with only 39% for patients in group B).
Conclusions:
In a substantial number of cases preexisting limb ischemia may be promoted by failed attempts at vascular reconstruction, thus leading to severe wound healing complications and a higher level of amputation.