Impact Of Open And Endovascular Caseload In Lower Limb Amputation In Portugal - An Analysis From 2000 To 2015

Effective revascularization is the cornerstone of limb salvage in chronic limb threatening ischemia. In recent years, less invasive endovascular revascularization techniques have supplanted surgical bypass as the primary mode of revascularization. The real impact of this transition is being increasingly questioned. This study aims to evaluate the endovascular evolution, and how it impacted the amputation rates nationwide since de beginning of the century.

Patients admitted to Portuguese public hospitals with peripheral arterial disease between 2000 and 2015 were selected. Of these, patients that underwent to limb revascularization and/ or limb amputation were evaluated. The information was obtained through the National Health Service administrative database. Three time periods (2000-2004, 2005-2009, 2010-2015) were considered to evaluate the evolution in amputation rates and type of revascularization.

The global number of revascularization episodes consistently increased along the 15 analyzed years. There were 25252 admissions for revascularization (55.1% open and 44.9% endovascular). The mean incidence of endovascular procedures significantly increased 5.8 times (p<0.01), and open surgery increased 1.3 times (p<0.01) when comparing the three time periods. 34633 limb amputations (65.3% major vs 34.7% minor) were realized along 15 years. The mean incidence of lower limb amputations increased by 1.5 times thanks to minor amputation, whose mean incidence increased two-fold while with the incidence of major amputations remained stable. Additionally, mean hospital mortality associated with revascularization episodes decreased from 10.6% to 8.2% (p<0.01), on 15-year follow-up.

There was a significative increase in revascularization episodes over the 15 years, suggesting better access to health services and/or better diagnostic accuracy. Endovascular procedures were the most practiced. This was along with an increase in the minor limb amputation, a stabilization in major amputations incidence. This nationwide study adds to the increasing body of knowledge in the ever-pertinent discussion of revascularization types and their benefits.