Multidisciplinary limb salvage care is associated with decreased mortality without increasing revascularization in...

The development and implementation of a multidisciplinary limb salvage program has been shown to improve amputation-free survival and decrease need for major amputations; however, the impact of this approach on patients who eventually progress to major amputation is unclear. The goal of this study is to assess the effect of a multidisciplinary limb salvage team (MLT) on revascularization rates before major amputation and outcomes after major amputation in patients in an urban setting.

Patients in a single health care system who underwent major lower extremity amputations between January 1, 2014, and December 31, 2021, were identified using Current Procedural Terminology codes within our electronic medical records. Patient demographic data, comorbidities, pre-amputation revascularization, limb salvage procedures, and 1-year mortality rates were collected by chart review. The χ² test, likelihood ratio tests, Mann-Whitney U test, and Student t test were used to compare patient variables and outcomes between before and after the launch of a MLT. Univariate and multivariate logistic regression analysis were used to assess patient characteristics associated with 30-day pre-amputation revascularization and one year mortality rates.

During the study period, 471 patients underwent major lower extremity amputations: 52% below-knee amputations, 47% above-knee amputations, and 1% through knee disarticulation. Comparing preamputation revascularization procedures stratified by involvement of a multidisciplinary limb care team, there was no significant difference in 30-day revascularization rate (30.2% vs 30.6%; P = .93). Preamputation revascularization rates within 90 days (45.1%% vs 45.8%; P = .87) and 1 year (56.1% vs 51.9%; P = .84) remained similar between groups as well. There was a statistically significant increase in 30-day preamputation debridement/minor amputation (25.9% vs 44.9%; P < .001) after MLT implementation; this significant increase was also shown within 90 days and 1 year before major amputation. The 1-year mortality rate in above-knee amputations (28% vs 18.7%; P = .15) was not significantly different after MLT implementation, but 1-year mortality in the major amputations (26.4% vs 14.3%; P = .002) and below-knee amputations (24.8% vs 12.2%; P = .013) groups were significantly different after MLT implementation. Patient characteristics associated with increased 30-day pre-amputation revascularization included hypertension (odds ratio [OR], 2.1; 95% CI, 1.2-3.8), smoking status (OR, 1.7; 95% CI, 1.1-2.6), and requiring debridement/minor amputation within 30 days before major amputation (OR, 2.3; 95% CI, 1.4-3.6). Patients older than 65 (OR, 3.2; 95% CI, 1.6-6.3) with end-stage renal disease (OR, 2.7; 95% CI, 1.5-4.9) were associated with higher risk for 1-year mortality. Implementation of limb salvage program was associated with improved 1-year postamputation mortality overall (OR, 0.54; 95% CI, 0.31-0.96).

For patients with chronic limb-threatening ischemia who eventually progressed to require major lower extremity amputations, the implementation of a limb salvage program did not change pre-amputation revascularization practice. However, it was associated with significantly improved 1-year postamputation mortality. Our findings further support the global vascular guidelines, demonstrating the benefit of limb salvage services in patients with major amputations.