Risk Factors for Unplanned Higher-Level Re-Amputation and Mortality after Lower Extremity Amputation in Chronic Limb-Threatening Ischemia
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. Definition of Terms
2.3. Study Outcomes
2.4. Data Collection
2.5. Statistical Analysis
3. Results
3.1. Characteristics of the Study Population
3.2. UHRA
3.3. Secondary Outcomes
3.4. Pooled Data Outcomes
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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N (%) | |
---|---|
(A) | |
Median age, years (IQR) | 65 (57, 75) |
Sex (n = 182) | |
Female | 54 (29.3) |
Male | 128 (70.7) |
Race (n = 173) | |
White | 89 (51.5) |
Non-white | 84 (48.6) |
Ambulatory status (n = 182) | |
Ambulatory | 60 (33.0) |
Ambulatory with assistance | 91 (50.0) |
Non-ambulatory | 31 (17.0) |
Living status (n = 178) | |
Home | 162 (91.0) |
Other | 16 (9.0) |
Medical history | |
Stroke (n = 182) | 18 (9.9) |
Coronary artery disease (n = 177) | 81 (45.8) |
Myocardial infarction (n = 177) | 29 (16.4) |
Congestive heart failure (n = 178) | 46 (25.8) |
Hypertension (n = 178) | 160 (89.9) |
Hyperlipidemia (n = 178) | 86 (48.3) |
Atrial fibrillation (n = 178) | 38 (21.4) |
Chronic obstructive pulmonary disease (n = 178) | 24 (13.5) |
End-stage renal disease (n = 178) | 55 (30.9) |
Diabetes mellitus (n = 178) | 126 (70.8) |
Malignancy (n = 178) | 26 (14.6) |
Smoking (n = 180) | |
Never | 74 (41.1) |
Former | 79 (43.9) |
Current | 27 (15.0) |
Medications | |
Statin (n = 178) | 130 (73.0) |
Antiplatelet (n = 178) | 122 (68.5) |
Anticoagulation (n = 178) | 53 (29.8) |
Dual anti-platelet (n = 178) | 37 (20.8) |
Optimal medical therapy (n = 182) | 102 (56.0) |
(B) | |
Toe | 118 (58.1) |
Transmetatarsal | 20 (9.9) |
Below-knee | 37 (18.2) |
Through- or above-knee | 28 (13.8) |
Patient and Limb Characteristic | No UHRA 167 Limbs (82.3%) | UHRA 36 Limbs (17.7%) | p Value |
---|---|---|---|
Age, mean (SD) [a] | 65.40 (12.5) | 64.72 (13.0) | 0.79 |
Sex | 0.04 | ||
Female | 52 (91.2) | 5 (8.8) | |
Male | 114 (78.6) | 31 (21.4) | |
Race | 0.58 | ||
Non-white | 82 (83.7) | 16 (16.3) | |
White | 75 (80.0) | 19 (20.2) | |
Ambulatory status | 0.65 | ||
Ambulatory | 57 (86.4) | 9 (13.6) | |
Ambulatory with assistance | 81 (81.0) | 19 (19.0) | |
Non-ambulatory | 29 (80.6) | 7 (19.4) | |
Living situation | 0.70 | ||
Home | 147 (82.6) | 31 (17.4) | |
Other | 15 (80.0) | 4 (21.1) | |
Medical history | |||
Stroke | 17 (85.0) | 3 (15.0) | 1.00 |
Coronary artery disease | 70 (77.8) | 20 (22.2) | 0.17 |
Myocardial infarction | 28 (84.9) | 5 (15.2) | 0.81 |
Congestive heart failure | 41 (77.4) | 12 (22.6) | 0.30 |
Hypertension | 144 (81.8) | 32 (18.2) | 1.00 |
Hyperlipidemia | 74 (79.6) | 19 (20.4) | 0.46 |
Atrial fibrillation | 32 (74.4) | 11 (25.6) | 0.17 |
Chronic obstructive pulmonary disease | 22 (75.9) | 7 (24.1) | 0.36 |
End-stage renal disease | 52 (82.5) | 11 (17.5) | 1.00 |
Diabetes mellitus | 116 (81.7) | 26 (18.3) | 0.84 |
Malignancy | 23 (82.1) | 5 (17.9) | 1.00 |
Smoking status | 0.44 | ||
Never | 65 (81.3) | 15 (18.8) | |
Former | 71 (79.8) | 18 (20.2) | |
Current | 29 (90.6) | 3 (9.4) | |
Medications | |||
Statin | 114 (79.7) | 29 (20.3) | 0.15 |
Antiplatelet | 107 (80.5) | 26 (19.6) | 0.37 |
Anticoagulation | 45 (73.8) | 16 (26.2) | 0.05 |
Dual antiplatelet | 29 (76.3) | 9 (23.7) | 0.34 |
Optimal medical therapy | 90 (79.7) | 23 (20.4) | 0.30 |
Non-invasive vascular testing | |||
Waveform—femoral | 1.00 | ||
Multiphasic | 149 (81.0) | 35 (19.0) | |
Abnormal | 4 (100.0) | 0 (0.0) | |
Waveform—popliteal | 0.60 | ||
Multiphasic | 135 (80.8) | 32 (19.2) | |
Abnormal | 18 (85.7) | 3 (14.3) | |
Waveform—ankle | 0.12 | ||
Multiphasic | 87 (86.1) | 14 (13.9) | |
Abnormal | 67 (77.0) | 20 (23.0) | |
ABI | 0.24 | ||
0.8–1.4 | 47 (82.5) | 10 (17.5) | |
0.5–0.8 | 19 (67.9) | 9 (32.1) | |
≤0.5 | 25 (89.3) | 3 (10.7) | |
Invalid | 65 (84.4) | 12 (15.6) | |
Toe pressure | 0.04 | ||
≥30 mm Hg | 73 (81.1) | 17 (18.9) | |
<30 mm Hg | 11 (57.9) | 8 (42.1) | |
0 mm Hg | 47 (87.0) | 7 (13.0) | |
Angiographic findings | |||
Patent common femoral artery | 115 (79.9) | 29 (20.1) | 0.99 |
Patent profunda femoris artery | 115 (80.4) | 28 (19.6) | 0.26 |
Patent genicular arteries, n (%) | 0.77 | ||
4 or 5 | 64 (79.0) | 17 (21.0) | |
3 or fewer | 43 (76.8) | 13 (23.2) | |
WIfI 1-year amputation risk | 0.99 | ||
Very low or low risk | 29 (80.6) | 7 (19.4) | |
Moderate or high risk | 104 (80.6) | 25 (19.4) | |
Index amputation type | 0.03 | ||
Toe | 92 (78.0) | 26 (22.0) | |
Transmetatarsal | 14 (70.0) | 6 (30.0) | |
Below-knee | 34 (92.0) | 3 (8.1) | |
Through- or above-knee | 27 (96.4) | 1 (3.6) | |
Indication for index amputation | 0.27 | ||
Dry gangrene | 62 (75.6) | 20 (24.4) | |
Any infection | 77 (87.5) | 11 (12.5) | |
Nonhealing wound or rest pain | 28 (84.9) | 5 (15.2) | |
Infection present | 117 (85.4) | 20 (14.6) | 0.12 |
Index amputation, open or closed | 0.70 | ||
Closed | 85 (83.3) | 17 (16.7) | |
Partially open or open | 82 (81.2) | 19 (18.8) | |
Ipsilateral revascularization prior to or concomitant with index amputation | 65 (74.7) | 22 (25.3) | 0.03 |
Revascularization after index amputation | 19 (65.5) | 10 (34.5) | 0.01 |
Debridement after index amputation | 14 (66.7) | 7 (33.3) | 0.05 |
Adjusted Odds Ratios (95% CI) | |||
---|---|---|---|
UHRA (n = 36) | Death within One Year (n = 36) | Composite (n = 74) | |
Age | 1.01 (0.98–1.04) | 1.01 (0.98–1.04) | 0.98 (0.95–1.00) † |
Male (Ref: Female) | 2.58 (0.93–7.17) † | 0.37 (0.15–0.89) * | 1.48 (0.73–3.01) |
Non-white (Ref: White) | 1.48 (0.70–3.11) | 0.63 (0.28–1.44) | 0.99 (0.52–1.86) |
Ambulatory status (Ref: Ambulatory) | |||
Ambulatory with assistance | 2.36 (0.86–6.51) † | 4.31 (1.20–15.49) * | 1.52 (0.72–3.21) |
Non-ambulatory | 6.74 (1.74–26.18) ** | 4.13 (0.80–21.39) † | 1.44 (0.54–3.87) |
Living status (Ref: Home) | |||
Other | 0.97 (0.28–3.44) | 0.40 (0.67–2.41) | 0.80 (0.26–2.49) |
Medical history | |||
Stroke (Ref: No) | 0.84 (0.20–3.42) | 0.43 (0.08–2.30) | 1.24 (0.46–3.36) |
Coronary artery disease (Ref: No) | 2.00 (0.88–4.58) | 3.93 (1.56–9.87) ** | 0.91 (0.48–1.72) |
Myocardial infarction (Ref: No) | 0.91 (0.34–2.39) | 2.22 (0.86–5.76) | 1.50 (0.67–3.39) |
Congestive heart failure (Ref: No) | 1.36 (0.61–3.04) | 4.90 (1.96–12.29) ** | 0.88 (0.43–1.84) |
Hyperlipidemia (Ref: No) | 1.42 (0.64–3.15) | 0.91 (0.41–2.00) | 1.01 (0.53–1.93) |
Atrial fibrillation (Ref: No) | 1.56 (0.68–3.59) | 2.49 (0.82–7.54) | 0.55 (0.25–1.21) |
Chronic obstructive pulmonary disease (Ref: No) | 2.31 (0.87–6.08) † | 2.26 (0.73–6.98) | 1.17 (0.44–3.12) |
End-stage renal disease (Ref: No) | 1.07 (0.46–2.48) | 7.54 (3.10–18.34) *** ‡ | 0.97 (0.46–2.04) |
Diabetes mellitus (Ref: No) | 0.78 (0.32–1.94) | 1.05 (0.41–2.69) | 0.77 (0.34–1.73) |
Malignancy (Ref: No) | 0.93 (0.35–2.51) | 1.61 (0.61–4.30) | 1.61 (0.64–4.07) |
Smoking Status (Ref: Never) | |||
Former | 1.10 (0.46–2.65) | 0.53 (0.22–1.28) | 1.22 (0.59–2.52) |
Current | 0.37 (0.09–1.55) | 1.05 (0.26–4.15) | 1.18 (0.39–3.53) |
Medications | |||
Statin (Ref: No) | 2.39 (0.84–6.78) | 1.73 (0.65–4.61) | 1.57 (0.76–3.24) |
Antiplatelet (Ref: No) | 2.02 (0.78–5.24) | 1.03 (0.45–2.37) | 0.74 (0.37–1.47) |
Anticoagulation (Ref: No) | 3.33 (1.43–7.72) ** | 0.70 (0.26–1.93) | 1.43 (0.69–2.98) |
Dual antiplatelet (Ref: No) | 1.87 (0.71–4.93) | 1.74 (0.72–4.17) | 0.94 (0.45–2.00) |
Optimal medical therapy (Ref: No) | 1.92 (0.83–4.48) | 1.34 (0.59–3.06) | 0.88 (0.46–1.68) |
Non-invasive vascular testing | |||
Abnormal waveform—femoral (Ref: Multiphasic) | ----- | 1.15 (0.08–17.35) | ----- |
Abnormal waveform—popliteal (Ref: Multiphasic) | 1.53 (0.44–7.14) | 1.79 (0.48–6.73) | 1.07 (0.40–2.88) |
Abnormal waveform—ankle (Ref: Multiphasic) | 3.12 (1.30–7.46) * | 1.59 (0.67–3.77) | 1.53 (0.75–3.13) |
ABI (Ref: 0.8–1.4) | |||
0.5–0.8 | 2.88 (0.79–10.48) | 1.82 (0.45–7.39) | 1.16 (0.41–3.32) |
≤0.5 | 2.76 (0.50–15.16) | 0.87 (0.17–4.44) | 0.61 (0.19–1.99) |
Invalid | 0.97 (0.33–2.80) | 4.79 (1.44–15.29) * | 0.71 (0.30–1.65) |
Toe pressure (Ref: ≥30 mm Hg) | |||
<30 mm Hg | 4.89 (1.52–15.78) ** | 2.82 (0.75–10.66) | 1.18 (0.37–3.75) |
0 mm Hg | 1.16 (0.36–3.73) | 3.34 (0.98–11.36) † | 0.74 (0.29–1.86) |
Angiographic findings Patent genicular arteries (Ref: 4 or 5) | |||
≤3 | 1.11 (0.45–2.75) | 0.47 (0.16–1.35) | 1.43 (0.65–3.19) |
WIfI 1-year amputation risk (Ref: Very low/low risk) | |||
Moderate/high risk | 1.13 (0.37–3.46) | 4.55 (0.94–22.10) † | 1.89 (0.80–4.51) |
Index amputation type (Ref: Toe) | |||
TMA | 1.64 (0.51–5.23) | 2.39 (0.64–8.88) | 0.66 (0.19–2.23) |
BKA | 0.22 (0.05–0.98) * | 1.00 (0.36–2.81) | 0.34 (0.15–0.74) ** |
TKA or AKA | 0.15 (0.02–1.15) † | 1.28 (0.42–3.93) | 0.22 (0.09–0.58) ** |
Indication (Ref: Dry gangrene) | |||
Any infection | 0.42 (0.17–1.03) † | 0.35 (0.13–0.90) * | 1.08 (0.52–2.27) |
Nonhealing wound or rest pain | 1.18 (0.32–4.33) | 0.73 (0.21–2.62) | 0.82 (0.33–2.09) |
Infection (Ref: None) | 0.35 (0.15–0.78) * | 1.31 (0.48–3.52) | 0.72 (0.35–1.50) |
Partially open or open index amputation (Ref: Closed) | 0.57 (0.25–1.29) | 1.00 (0.38–2.65) | 2.49 (1.18–5.23) * |
Revascularization prior to or concomitant to index amputation (Ref: No) | 2.19 (0.88–5.49) † | 0.81 (0.35–1.86) | 0.89 (0.46–1.71) |
Revascularization after index amputation (Ref: No) | 2.16 (0.89–5.24) † | 0.45 (0.12–1.65) | ----- |
Debridement after index amputation (Ref: No) | 4.18 (1.13–15.50) * | 0.47 (0.10–2.26) | ----- |
UHRA (Ref: No) | ----- | 2.00 (0.76–5.25) | ----- |
Patient Characteristic | Hazard Ratio (95% CI) | p Value |
---|---|---|
Age | 1.00 (0.98–1.03) | 0.75 |
Male (Ref: Female) | 0.41 (0.20–0.83) | 0.01 |
Non-white (Ref: White) | 0.68 (0.33–1.37) | 0.28 |
Ambulatory status at index (Ref: Ambulatory) | ||
Ambulatory with assistance | 3.76 (1.11–12.78) | 0.03 |
Non-ambulatory | 3.65 (0.78–17.03) | 0.10 |
Living situation (Ref: Home) | ||
Other | 0.44 (0.08–2.37) | 0.34 |
Medical history | ||
Stroke (Ref: No) | 0.45 (0.10–1.98) | 0.29 |
Coronary artery disease (Ref: No) | 2.97 (1.31–6.71) | 0.01 |
Myocardial infarction (Ref: No) | 1.91 (0.86–4.26) | 0.11 |
Congestive heart failure (Ref: No) | 3.51 (1.64–7.51) | 0.001 |
Hyperlipidemia (Ref: No) | 0.90 (0.45–1.80) | 0.76 |
Atrial fibrillation (Ref: No) | 2.32 (0.78–6.86) | 0.13 |
Chronic obstructive pulmonary disease (Ref: No) | 1.98 (0.78–5.05) | 0.15 |
End-stage renal disease (Ref: No) | 5.35 (2.51–11.43) ‡ | <0.001 |
Malignancy (Ref: No) | 1.46 (0.62–3.46) | 0.39 |
Smoking status (Ref: Never) | ||
Former | 0.61 (0.27–1.35) | 0.22 |
Current | 1.09 (0.31–3.78) | 0.89 |
Medications | ||
Statin (Ref: No) | 1.59 (0.66–3.87) | 0.30 |
Antiplatelet (Ref: No) | 1.00 (0.47–2.13) | 1.00 |
Anticoagulation (Ref: No) | 0.73 (0.30–1.78) | 0.49 |
Dual antiplatelet (Ref: No) | 1.85 (0.85–4.03) | 0.12 |
Optimal medical therapy (Ref: No) | 1.32 (0.63–2.73) | 0.46 |
Non-invasive vascular testing | ||
Abnormal waveform—femoral (Ref: Multiphasic) | 0.93 (0.11–7.77) | 0.95 |
Abnormal waveform—popliteal (Ref: Multiphasic) | 1.57 (0.49–5.04) | 0.45 |
Abnormal waveform—ankle (Ref: Multiphasic) | 1.35 (0.62–2.94) | 0.45 |
ABI (Ref: 0.8–1.4) | ||
0.5–0.8 | 1.55 (0.44–5.42) | 0.50 |
≤0.5 | 0.82 (0.19–3.60) | 0.79 |
Invalid | 3.48 (1.17–10.36) | 0.03 |
Toe pressure (Ref: ≥30 mm Hg) | ||
<30 mm Hg | 2.56 (0.78–8.42) | 0.12 |
0 mm Hg | 2.61 (0.89–7.68) | 0.08 |
Angiographic findings Patent genicular arteries (Ref: 4 or 5) | ||
≤3 | 0.54 (0.21–1.39) | 0.20 |
WIfI 1-year amputation risk (Ref: Very/low risk) | ||
Moderate/high risk | 3.88 (0.84–17.80) | 0.08 |
Amputation type (Ref: Toe) | ||
Transmetatarsal | 1.86 (0.68–5.05) | 0.23 |
Below-knee | 0.97 (0.38–2.46) | 0.95 |
Through- or above-knee | 1.26 (0.49–3.24) | 0.63 |
Indication (Ref: Dry gangrene) | ||
Any infection | 0.40 (0.17–0.96) | 0.04 |
Nonhealing wound or rest pain | 0.78 (0.24–2.57) | 0.68 |
Infection (Ref: None) | 1.29 (0.52–3.22) | 0.58 |
Partially open or open (Ref: Closed) | 0.99 (0.40–2.45) | 0.99 |
Revascularization prior to or concomitant to index amputation (Ref: No) | 0.81 (0.36–1.80) | 0.60 |
Revascularization after index amputation (Ref: No) | 0.51 (0.16–1.65) | 0.26 |
Debridement after index amputation (Ref: No) | 0.51 (0.12–2.12) | 0.35 |
UHRA | 1.87 (0.80–4.37) | 0.24 |
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Guerra, A.; Guo, M.; Boyd, R.M.; Zakharevich, M.; Hoel, A.W.; Vavra, A.K.; Chung, J.W.; Ho, K.J. Risk Factors for Unplanned Higher-Level Re-Amputation and Mortality after Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. J. Clin. Med. 2024, 13, 4020. https://doi.org/10.3390/jcm13144020
Guerra A, Guo M, Boyd RM, Zakharevich M, Hoel AW, Vavra AK, Chung JW, Ho KJ. Risk Factors for Unplanned Higher-Level Re-Amputation and Mortality after Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. Journal of Clinical Medicine. 2024; 13(14):4020. https://doi.org/10.3390/jcm13144020
Chicago/Turabian StyleGuerra, Andres, Michelle Guo, Riley M. Boyd, Marina Zakharevich, Andrew W. Hoel, Ashley K. Vavra, Jeanette W. Chung, and Karen J. Ho. 2024. "Risk Factors for Unplanned Higher-Level Re-Amputation and Mortality after Lower Extremity Amputation in Chronic Limb-Threatening Ischemia" Journal of Clinical Medicine 13, no. 14: 4020. https://doi.org/10.3390/jcm13144020
APA StyleGuerra, A., Guo, M., Boyd, R. M., Zakharevich, M., Hoel, A. W., Vavra, A. K., Chung, J. W., & Ho, K. J. (2024). Risk Factors for Unplanned Higher-Level Re-Amputation and Mortality after Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. Journal of Clinical Medicine, 13(14), 4020. https://doi.org/10.3390/jcm13144020