Revascularisation or amputation?

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At the European Society of Vascular Surgery (ESVS) meeting, in September 2008, Dr Jonathan Beard, Sheffield Vascular Institute, UK, posed the question ‘Is there a place for primary amputation?’

Beard began by describing what he considers a “successful treatment” of critical limb ischaemia (CLI) to the physician: patency, low reintervention rates, good limb salvage, cost effectiveness and the prolongation of life. From the patient perspective, relief of pain, improvement in quality of life, the maintenance of mobility, limb salvage and increased life expectancy amount to successful treatment. As for the “ideal reconstruction”, or revascularisation, Beard describes an uncomplicated operation that achieves long-term limb salvage and relief of pain, without doctors having to make further interventions. He notes that this describes only 20% of real-life cases.

Considering whether amputation is superior or inferior to reconstruction (successful or not), Beard explains that the evidence is patchy, with no randomised trials having been carried out, no case-matched studies, and only a few cohort or population studies. Most evidence is gleaned from retrospective series’ from ‘centres of excellence’. The Transatlantic Inter-Society Consensus (TASC) guidelines concerning primary amputation recommend it only for unreconstructable arterial disease, necrosis of a significant weight-bearing portion of the foot or fixed flexion contracture of the leg. They note the very limited life expectancy of amputees and recommend that “a reconstructive procedure should be attempted if there is a 25% chance of saving a useful limb for a patient for at least a year.”

As regards cost-effectiveness, Beard outlined the average costs he found for different treatments for CLI (published in the European Journal of Vascular and Endovascular Surgery), with primary amputation costing £10,162 to a reconstruction’s average cost of £6,766. However, a failed reconstruction requiring further treatment costs around £12,927. Across 100 patients he found that with 100% successful bypasses the cost was £528,900, rising to £800,000 for a group treated with 100% primary amputation and £1,226,400 with 100% bypasses that only achieve 25% limb salvage.

 

Levels of amputation

Beard discussed the level of amputation carried out and said that there was “no point” in performing a below-the-knee amputation if the patient was unlikely to walk, for example because they were bedbound. For those who will not walk he recommends a modified Gritti-Stokes or through-knee amputation, due to its good healing and because it leaves the quads intact and a long lever for transfers. Above-the-knee amputation “gives a short stump and risks flexion contracture of the hip.”

Citing his investigation ‘Amputation vs. revascularisation disease-specific quality of life study’, Beard described it as a prospective study over two years that looked at 150 patients with CLI undergoing either amputation or revascularisation. Their quality of life was measured before treatment and followed up at six and 12 months. There was a single observer in each case in the form of an occupational therapist who assessed the patient’s pain, mobility, anxiety and depression, self-care and outside activities. Beard and co-investigators found that revascularisation and amputation both reduced pain and improved self-care. Revascularisation increased mobility. Lifestyle in general was not improved in either group and Beard commented that there was a large variation in results depending on the “personality” of the patient and environmental factors such as family support.

In summary, he said that there is no good evidence to choose revascularisation over amputation, as although it is more cost effective when successful and can restore some mobility, amputation can improve quality of life and should still be an option under the right circumstances. Treatment must be tailored to individual patients depending on outside factors and choice.

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