Trends in Lower Extremity Major Amputation during the COVID-19 Pandemic

The Coronavirus disease 2019 (COVID-19) pandemic temporarily halted elective and nonurgent surgeries, including revascularization, to allocate resources to address critically ill patients. Simultaneously, COVID-19-related vascular complications and increases in critical illness led to major amputation. We evaluated trends in major amputation during the pandemic, both acutely and subacutely, secondary to delays in revascularization.

The National Surgical Quality Improvement Program database was queried for major lower extremity amputations and lower extremity revascularizations from 2017 to 2021. The proportion of major amputations to the sum of lower extremity revascularizations and amputations was calculated for each quarter. Perioperative and postoperative variables were compared for amputations before (2017-2019) and during the pandemic (2020-2021).

We identified 86,416 lower extremity revascularizations and 14,800 major amputations over the 5-year period. Although major amputations decreased overall, there was a sharp increase hyperacutely to 882 cases during the national elective surgery shutdown. Revascularizations also declined steadily. Following the March 2020 Emergency Declaration, the proportion of lower extremity procedures that were major amputations peaked at 24.6%, before returning to prepandemic levels. Patients who underwent amputation in 2020-2021 had significantly higher rates of emergency classification (23 vs. 15%), mechanical ventilation (2.1 vs. 1.2%), congestive heart failure (16 vs. 7%), wound infection (4.4 vs. 3%), pneumonia (3.7 vs. 3.4%), unplanned reintubation (4.2 vs. 3.5%), stroke (1.3 vs. 0.9%), cardiac arrest (3.1 vs. 2.4%), and septic shock (2.3 vs. 1.8%).

There was a sharp increase in major amputations during the height of the pandemic. Following this acute period, however, the proportion of amputations was similar to the prepandemic era, suggesting no increase in limb loss despite delays in nonurgent revascularization, although postoperative outcomes were more morbid.