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      All-Cause Mortality Amongst Patients Undergoing Above and Below Knee Amputation in a Regional Vascular Centre within 2014-2015

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          ABSTRACT

          Background

          Major lower limb amputation remains a common treatment for patients with peripheral vascular disease (PVD) in whom other measures have failed. It has been associated with high morbidity and mortality, including risks from venous thromboembolism (VTE).

          Methods

          A two-year retrospective cohort study was conducted involving 79 patients who underwent major lower limb amputation (below- or above-knee amputation) between January 2014 and December 2015 in a single tertiary referral centre. Amputation procedures were performed for reasons relating to complications of PVD and/or diabetes mellitus. Patients were followed-up to investigate all-cause mortality rates and VTE events using the Northern Ireland Electronic Care Record database (mean follow-up time 17 months).

          Results

          Of the 79 patients, there were 52 male and 27 female. Mean age at time of surgery was 72 years (range 34-99 years). Forty-six patients (58%) suffered from diabetes mellitus, 29 (35%) heart failure, 31 (39%) chronic kidney disease (CKD) and 10 (13%) chronic obstructive pulmonary disease (COPD). Twenty patients (25%) were on anticoagulant therapy, and 53 (67%) were on antiplatelet therapy.

          Thirty-five patients (44%) died during follow-up; mean age at death was 74 years. No statistically significant association was found between mortality rate and the level of amputation (p=0.3702), gender (p=0.3507), or comorbid diabetic mellitus (p=0.1127), heart failure (p=0.1028), CKD (p=0.0643) or COPD (p=0.4987).

          Two patients experienced radiologically-confirmed non-fatal pulmonary emboli and two patients developed radiologically-confirmed deep vein thrombosis.

          Conclusions

          The results are in agreement with current literature that amputation is associated with significant mortality, with almost half of the study population dying during follow-up. Further work should explore measures by which mortality rates may be reduced.

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          Most cited references 15

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          Peripheral arterial disease in people with diabetes.

            (2003)
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            Epidemiology, classification, and modifiable risk factors of peripheral arterial disease

            Peripheral arterial disease (PAD) is part of a global vascular problem of diffuse atherosclerosis. PAD patients die mostly of cardiac and cerebrovascular-related events and much less frequently due to obstructive disease of the lower extremities. Aggressive risk factors modi. cation is needed to reduce cardiac mortality in PAD patients. These include smoking cessation, reduction of blood pressure to current guidelines, aggressive low density lipoprotein lowering, losing weight, controlling diabetes and the use of oral antiplatelet drugs such as aspirin or clopidogrel. In addition to quitting smoking and exercise, cilostazol and statins have been shown to reduce claudication in patients with PAD. Patients with critical rest limb ischemia or severe progressive claudication need to be treated with revascularization to minimize the chance of limb loss, reduce symptoms, and improve quality of life.
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              Major lower extremity amputation: outcome of a modern series.

              Major lower extremity amputation results in significant morbidity and mortality. Retrospective database query and medical record review for January 1, 1990, to December 31, 2001. Mean follow-up was 33.6 months. Academic tertiary care center. Nine hundred fifty-nine consecutive major lower extremity amputations in 788 patients, including 704 below-knee amputations (BKAs) (73.4%) and 255 above-knee amputations (AKAs) (26.6%). Patient survival, cardiac morbidity, infectious complications, and subsequent operation. Overall 30-day mortality was 8.6%, worse for AKA (16.5%) than BKA (5.7%) patients (P<.001). Thirty-day mortality for guillotine amputation for sepsis control was 14.3% compared with 7.8% for closed amputation (P =.03). Complications included cardiac (10.2%), wound infection (5.5%), and pneumonia (4.5%). Twelve AKA (4.7%) and 129 BKA (18.4%) limbs required subsequent operation. Only 66 BKAs (9.4%) required conversion to AKA (average, 77.1 days postoperatively). Overall survival was 69.7% and 34.7% at 1 and 5 years, respectively. Survival was significantly worse for AKAs (50.6% and 22.5%) than BKAs (74.5% and 37.8%) (P<.001). Survival in patients with diabetes mellitus (DM) was 69.4% and 30.9% vs 70.8% and 51.0% in patients without DM at 1 and 5 years, respectively (P =.002). Survival in end-stage renal disease patients was 51.9% and 14.4% vs 75.4% and 42.2% in patients without renal failure at 1 and 5 years, respectively (P<.001). Major amputation continues to result in significant morbidity and mortality. Survivors with BKA require revision or conversion to AKA infrequently. Long-term survival is dismal for patients with DM and end-stage renal disease and those undergoing AKA.
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                Author and article information

                Journal
                Ulster Med J
                Ulster Med J
                umj
                The Ulster Medical Journal
                The Ulster Medical Society
                0041-6193
                22 January 2019
                January 2019
                : 88
                : 1
                : 30-35
                Affiliations
                [1 ]The Vascular Centre, Royal Victoria Hospital Belfast. Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Rd, Belfast BT12 6BA. N. Ireland
                [2 ]Department of Paleontology. Faculty of Earth and Atmospheric Science. University of Alberta 1-26 Earth Sciences Building. Edmonton, Alberta T6G 2E3 Canada
                Author notes
                Correspondence: Ms Grace Kennedy, E-mail: gkennedy15@ 123456qub.ac.uk
                Article
                6342035
                Copyright © 2019 Ulster Medical Society

                The Ulster Medical Society grants to all users on the basis of a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence the right to alter or build upon the work non-commercially, as long as the author is credited and the new creation is licensed under identical terms.

                Categories
                Clinical Paper

                Medicine

                deep vein thrombosis, vascular surgery, amputation, all-cause mortality, pulmonary embolism

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