Revascularization or amputation

The factors which determine the choice, revascularization or amputation of an ischaemic leg are very numerous, variable and sometimes also related. They are concerned with the extent and course of the gangrene, the general condition of the patient and the risk of operation, the technical operability in terms of arterial reconstruction, the skill and judgement of the vascular surgeon, the motivation and life expectancy of the patient, as well as the facilities at the limb-fitting centre. In principle, arterial reconstruction should be the primary consideration in all patients with severe ischaemia of a leg, and threatened with loss of the limb. This implies the need for evaluation by a vascular surgeon. If arterial reconstruction is impossible or undesirable and if lumbar sympathectomy is not indicated either, then if amputation is necessary it must be decided, when is it necessary, and whether a below-knee or an above-knee amputation is possible. The patient with severe arterial circulatory disorders is best served when the vascular surgeon who is responsible for the arterial reconstruction, also assumes responsibility for determining the timing and the level of an amputation, and in some hospitals even for doing the amputation. In other words, the same doctor, preferably the vascular surgeon, has to be responsible for the selection of the patients and the judgement whether the patient is a candidate for revascularization or amputation.