Infrainguinal Reconstruction vs Primary Amputation in Critical Limb Ischemia

Kim, Yong Sung; Kim, Do Kyun; Lee, Tae Seok; Park, Ho Chul

Abstract

PURPOSE: Many physicians persist in the belief that attempted revascularization is inappropriate for many patients with limbs threatened by ischemia. They continue to recommend primary amputation. Unfortunately, amputation for lower-extremity ischemia is frequently followed by infirmity, institutionalization, and death for the patient. We have reviewed our experiences on primary amputation versus infrainguinal revascularization.
METHODS
Between Jan. 1992 and Dec. 1997, 56 infrainguinal reconstructions and 28 primary amputations were performed in 84 patients with critical ischemia of lower extremity.
RESULTS
The male to female ratio was 11 to 1, and the most prevalent age group was the 6th decade. The etiologies were atherosclerosis obliterans in 82.1% and Buergers disease in 10.7%. The associated diseases were hypertension (38.1%), diabetes (27.4%) and cerebrovascular accidents (21.4%). The locations were iliac in 8.3%, femoral in 73.8%, popliteal in 7.1%, tibial in 9.5%, and peroneal in 2.4%. Clinical categories were divided into acute limb ischemia in 27.4% (grade II in 13.1% and III in 14.3%), and chronic limb ischemia in 72.6% (grade I in 13.1%, II in 32.1%, and III in 27.4%). Preoperative risk was evaluated with Goldmans index, ASA scale, and Eagles criteria. According to Eagles criteria, 24 patients (28.6%) showed a low risk, 49 patients (58.3%) had a moderate risk, and 11 patients (13.1%) had a high risk. Of the 84 patients, the following surgical techniques were used, femoro-popliteal bypass in 36 (64.3%), femoro-femoral in 13 (23.2%), femoro-tibial in 10 (17.9%), popliteo-tibial in 6 (10.7%), femoro-peroneal in 1 (1.2%), axillo-femoral in 1 (1.2%), below-knee amputation in 15 (53.6%), above-knee amputation in 12 (42.9%), and hip disarticulation in 1 (3.6%). The mean follow up period was 13.7 months. The mortality for revascularization was 3.6%, which was significantly different from the mortality of primary amputation (14.3%). The 1-month and 1-year and 2-year secondary graft patency rates were 90.8%, 85.3%, and 83.3%, respectively.
CONCLUSION
Patients who underwent revascularization had a lower perioperative mortality rate (P<0.05), a lower complication rate (P<0.05), and an increased long-term survival rate (P<0.05) than the group of patients who underwent primary amputation. In summary, the results of this present study suggest that all patients with limb threatened by ischemia should be treated with revascularization by an experienced vascular surgeon rather than with primary amputation.