Limb-threatening ischemia in the medically compromised patient: amputation or revascularization?

Area of Science:

• Vascular Surgery
• Limb Salvage Surgery
• Cardiovascular Risk Assessment

Background:

• Threatened limbs pose significant clinical challenges.
• Treatment decisions involve balancing amputation versus limb salvage.
• Patient comorbidities often influence treatment modality selection.

Purpose of the Study:

• To compare the clinical outcomes of infrainguinal revascularization and below-knee amputation for threatened limbs.
• To evaluate treatment efficacy in relation to patient medical risk stratification.
• To assess the impact of revascularization versus amputation on perioperative mortality, hospital stay, long-term survival, and ambulatory function.

Main Methods:

• Retrospective review of 362 patients with threatened limbs over 25 years.
• Stratification of patients into three classes based on Goldman Multifactorial Index of Cardiac Risk and American Society of Anesthesiologists classification.
• Comparison of infrainguinal revascularization (n=204) versus below-knee amputation (n=158), excluding cases with contraindications for amputation.

Main Results:

• Revascularization patients had lower perioperative mortality (p<0.05) and shorter hospital stays (p<0.05) compared to matched amputation patients.
• Infrainguinal revascularization resulted in increased long-term survival (p<0.05) and superior ambulatory ability (p<0.01).
• Benefits of revascularization were most pronounced in medically compromised patients.

Conclusions:

• Infrainguinal revascularization is a viable and beneficial treatment for threatened limbs, even in medically compromised patients.
• Limb salvage through revascularization improves survival and functional outcomes compared to amputation.
• Medically complex patients may benefit most from limb salvage attempts, challenging previous assumptions about surgical risk.