Lower extremity amputation in peripheral artery disease: improving patient outcomes

Aparna Swaminathan, Sreekanth Vemulapalli, Manesh R Patel, W Schuyler Jones, Aparna Swaminathan, Sreekanth Vemulapalli, Manesh R Patel, W Schuyler Jones

Abstract

Peripheral artery disease affects over eight million Americans and is associated with an increased risk of mortality, cardiovascular disease, functional limitation, and limb loss. In its most severe form, critical limb ischemia, patients are often treated with lower extremity (LE) amputation (LEA), although the overall incidence of LEA is declining. In the US, there is significant geographic variation in the performing of major LEA. The rate of death after major LEA in the US is approximately 48% at 1 year and 71% at 3 years. Despite this significant morbidity and mortality, the use of diagnostic testing (both noninvasive and invasive testing) in the year prior to LEA is low and varies based on patient, provider, and regional factors. In this review we discuss the significance of LEA and methods to reduce its occurrence. These methods include improved recognition of the risk factors for LEA by clinicians and patients, strong advocacy for noninvasive and/or invasive imaging prior to LEA, improved endovascular revascularization techniques, and novel therapies.

Keywords: lower extremity amputation; mortality; peripheral artery disease.

Figures

Figure 1
Figure 1
Conceptual framework of treatment of patients with peripheral artery disease (PAD).
Figure 2
Figure 2
Clinical outcomes after lower extremity (LE) amputation. The occurrence of death, myocardial infarction, and stroke in patients hospitalized for peripheral artery disease (PAD) with and without major LE amputation: cumulative incidence rates of all-cause mortality (top panel), myocardial infarction (middle panel), and stroke (bottom panel) after major LE amputation. Note: Reprinted from Am Heart J. Vol. 165(5). Jones WS, Patel MR, Dai D, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. Pages 809–815. © 2013, with permission from Elsevier. Abbreviations: w/o, without; w, with.
Figure 3
Figure 3
Geographic variation of major amputation of the lower extremity. Note: The rates of major amputation of the lower extremity per hospital referral region (when normalized to the US) from inpatient Medicare data from 2000 to 2008.

References

    1. Rooke TW, Hirsch AT, Misra S, et al. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011;58(19):2020–2045.
    1. Tendera M, Aboyans V, Bartelink ML, et al. ESC guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC) Eur Heart J. 2011;32(22):2851–2906.
    1. Heald CL, Fowkes FG, Murray GD, Price JF. Risk of mortality and cardiovascular disease associated with the ankle-brachial index: systematic review. Atherosclerosis. 2006;189(1):61–69.
    1. Subherwal S, Bhatt DL, Li S, et al. Polyvascular disease and long-term cardiovascular outcomes in older patients with non-ST-segment-elevation myocardial infarction. Circ Cardiovasc Qual Outcomes. 2012;5(4):541–549.
    1. Andras A, Ferket B. Screening for peripheral arterial disease. Cochrane Database Syst Rev. 2014;4:CD010835.
    1. Beckman JA, Jaff MR, Creager MA. The United States Preventive Services Task Force recommendation statement on screening for peripheral arterial disease: more harm than benefit? Circulation. 2006;114(8):861–866.
    1. Hooi JD, Kester AD, Stoffers HE, Rinkens PE, Knottnerus JA, van Ree JW. Asymptomatic peripheral arterial occlusive disease predicted cardiovascular morbidity and mortality in a 7-year follow-up study. J Clin Epidemiol. 2004;57(3):294–300.
    1. Twine CP, Coulston J, Shandall A, McLain AD. Angioplasty versus stenting for superficial femoral artery lesions. Cochrane Database Syst Rev. 2009;(2):CD006767.
    1. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-society Consensus (TASC) J Vasc Surg. 2000;31(1 Pt 2):S1–S296.
    1. Fowkes FG, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet. 2013;382(9901):1329–1340.
    1. Hirsch AT, Murphy TP, Lovell MB, et al. Gaps in public knowledge of peripheral arterial disease: the first national PAD public awareness survey. Circulation. 2007;116(18):2086–2094.
    1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463–e654.
    1. Peacock JM, Keo HH, Duval S, et al. The incidence and health economic burden of ischemic amputation in Minnesota, 2005–2008. Prev Chronic Dis. 2011;8(6):A141.
    1. Cruz CP, Eidt JF, Capps C, Kirtley L, Moursi MM. Major lower extremity amputations at a Veterans Affairs hospital. Am J Surg. 2003;186(5):449–454.
    1. Layden J, Michaels J, Bermingham S, Higgins B. Guideline Development Group. Diagnosis and management of lower limb peripheral arterial disease: summary of NICE guidance. BMJ. 2012;345:e4947.
    1. Jones WS, Patel MR, Dai D, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. Am Heart J. 2013;165(5):809–815.
    1. Jones WS, Patel MR, Dai D, et al. Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease: results from US Medicare 2000–2008. J Am Coll Cardiol. 2012;60(21):2230–2236.
    1. Schanzer A, Mega J, Meadows J, Samson RH, Bandyk DF, Conte MS. Risk stratification in critical limb ischemia: derivation and validation of a model to predict amputation-free survival using multicenter surgical outcomes data. J Vasc Surg. 2008;48(6):1464–1471.
    1. Goodney PP, Travis LL, Brooke BS, et al. Relationship between regional spending on vascular care and amputation rate. JAMA Surg. 2014;149(1):34–42.
    1. Olin JW, Allie DE, Belkin M, et al. ACCF/AHA/ACR/SCAI/SIR/SVM/SVN/SVS 2010 performance measures for adults with peripheral artery disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures, the American College of Radiology, the Society for Cardiac Angiography and Interventions, the Society for Interventional Radiology, the Society for Vascular Medicine, the Society for Vascular Nursing, and the Society for Vascular Surgery (Writing Committee to Develop Clinical Performance Measures for Peripheral Artery Disease) J Vasc Nurs. 2011;29(1):23–60.
    1. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction – executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction) Circulation. 2004;110(5):588–636.
    1. Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Circ Cardiovasc Qual Outcomes. 2012;5(1):94–102.
    1. Margolis DJ, Hoffstad O, Nafash J, et al. Location, location, location: geographic clustering of lower-extremity amputation among medicare beneficiaries with diabetes. Diabetes Care. 2011;34(11):2363–2367.
    1. Vemulapalli S, Greiner MA, Jones WS, Patel MR, Hernandez AF, Curtis LH. Peripheral arterial testing before lower extremity amputation among Medicare beneficiaries, 2000 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7(1):142–150.
    1. Jaff MR, Cahill KE, Yu AP, Birnbaum HG, Engelhart LM. Clinical outcomes and medical care costs among medicare beneficiaries receiving therapy for peripheral arterial disease. Ann Vasc Surg. 2010;24(5):577–587.
    1. Jude EB, Unsworth PF. Optimal treatment of infected diabetic foot ulcers. Drugs Aging. 2004;21(13):833–850.
    1. Werk M, Langner S, Reinkensmeier B, et al. Inhibition of restenosis in femoropopliteal arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation. 2008;118(13):1358–1365.
    1. Tepe G, Zeller T, Albrecht T, et al. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. NEJM. 2008;358(7):689–699.
    1. Stoner MC, deFreitas DJ, Phade SV, Parker FM, Bogey WM, Powell S. Mid-term results with laser atherectomy in the treatment of infrainguinal occlusive disease. J Vasc Surg. 2007;46(2):289–295.
    1. Charalambous N, Schafer PJ, Trentmann J, et al. Percutaneous intraluminal recanalization of long, chronic superficial femoral and popliteal occlusions using the Frontrunner XP CTO device: a single-center experience. Cardiovasc Intervent Radiol. 2010;33(1):25–33.
    1. Staniloae CS, Mody KP, Yadav SS, Han SY, Korabathina R. Endoluminal treatment of peripheral chronic total occlusions using the Crosser® recanalization catheter. J Invas Cardiol. 2011;23(9):359–362.
    1. Pigott JP, Raja ML, Davis T. A multicenter experience evaluating chronic total occlusion crossing with the Wildcat catheter (the CONNECT study) J Vasc Surg. 2012;56(6):1615–1621.
    1. Jones WS, Dolor RJ, Hasselblad V, et al. Comparative effectiveness of endovascular and surgical revascularization for patients with peripheral artery disease and critical limb ischemia: systematic review of revascularization in critical limb ischemia. Am Heart J. 2014;167(4):489–498.
    1. Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366(9501):1925–1934.
    1. Belch J, Hiatt WR, Baumgartner I, et al. Effect of fibroblast growth factor NV1FGF on amputation and death: a randomised placebo-controlled trial of gene therapy in critical limb ischaemia. Lancet. 2011;377(9781):1929–1937.
    1. Rajagopalan S, Mohler ER, 3rd, Lederman RJ, et al. Regional angiogenesis with vascular endothelial growth factor in peripheral arterial disease: a phase II randomized, double-blind, controlled study of adenoviral delivery of vascular endothelial growth factor 121 in patients with disabling intermittent claudication. Circulation. 2003;108(16):1933–1938.
    1. Morishita R, Aoki M, Hashiya N, et al. Safety evaluation of clinical gene therapy using hepatocyte growth factor to treat peripheral arterial disease. Hypertension. 2004;44(2):203–209.
    1. Tateishi-Yuyama E, Matsubara H, Murohara T, et al. Therapeutic angiogenesis for patients with limb ischaemia by autologous transplantation of bone-marrow cells: a pilot study and a randomised controlled trial. Lancet. 2002;360(9331):427–435.
    1. Jones WS, Annex BH. Growth factors for therapeutic angiogenesis in peripheral arterial disease. Curr Opin Cardiol. 2007;22(5):458–463.
    1. Powell RJ, Goodney P, Mendelsohn FO, Moen EK, Annex BH. Safety and efficacy of patient specific intramuscular injection of HGF plasmid gene therapy on limb perfusion and wound healing in patients with ischemic lower extremity ulceration: results of the HGF-0205 trial. J Vasc Surg. 2010;52(6):1525–1530.
    1. Jones WS, Schmit KM, Vemulapalli S, et al. Comparative Effectiveness Review No 118 (Prepared by the Duke Evidence-based Practice Center under Contract No 290–2007–10066-I.) Rockville, MD: Agency for Healthcare Research and Quality; 2013. Treatment Strategies for Patients with Peripheral Artery Disease. (AHRQ Publication No 13-EHC090-EF).
    1. Subherwal S, Anstrom KJ, Jones WS, et al. Use of alternative methodologies for evaluation of composite end points in trials of therapies for critical limb ischemia. Am Heart J. 2012;164(3):277–284.
    1. Joynt KE, Blumenthal DM, Orav EJ, Resnic FS, Jha AK. Association of public reporting for percutaneous coronary intervention with utilization and outcomes among Medicare beneficiaries with acute myocardial infarction. JAMA. 2012;308(14):1460–1468.
    1. Werner RM, Asch DA. The unintended consequences of publicly reporting quality information. JAMA. 2005;293(10):1239–1244.

Source: PubMed

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