Amputation Prevention Treatment

Complications of Amputation

The challenges of amputation extend beyond the obvious quality-of-life implications of immediate limb loss. Amputation brings with it a high likelihood of surgical and post-operative complications (20% to 37%), including wound infection (10% to 30%), deep vein thrombosis (13% to 26%), cardiac complications (9% to 10%), sepsis (9%), bleeding (8%), and renal failure (2% to 3%). In comparison, surgical care sees a 16% to 17% complication rate, while endovascular approaches only see a 5% to 9% complication rate [1].

Over 55% of patients who undergo amputation as a result of diabetes or PAD end up permanently disabled, and approximately the same amount never return to ambulatory status. Mortality is also strikingly high following amputation. In a recent US Medicare study, 1-year mortality following amputation for CLI was 40%, which was 10% higher than the subpopulation that did not undergo amputation [2]. From these data points it’s clear that the majority of patients are better off if they can avoid amputation altogether

Understanding Amputation Risk

In its later stages, PAD becomes critical limb ischemia (CLI). CLI represents an advanced clinical presentation of PAD in which disease causes rest pain, ulceration, and gangrene. Around 1% of all PAD patients progress to CLI, representing about 10% to 15% of those with claudication. Without intervention, individuals with CLI have a 25% mortality rate and a 25% amputation rate at one year following diagnosis. At 5 years, mortality jumps up to 55% [2].

Amputation appears to be more prevalent in specific demographics, including in African Americans and Native Americans where the amputation rate is nearly double that of non-Hispanic white individuals [3,4].

Amputation Prevention Treatment

Preventative efforts should begin as early as possible in the course of PAD, but implementing them requires diligent care providers, aggressive screening programs, and the right network of specialists. PAD guidelines recommend screening every individual over 65, individuals over 50 if they have diabetes or history of smoking, and individuals under 50 if they have diabetes and at least one additional risk factor. As comprehensive as this approach should be, many patients still slip through and go undiagnosed until it’s too late. As physicians, we need to redouble our efforts to catch PAD in its early stages by looking out for telling risk factors and symptoms, and also in its later stages by shifting focus from the wound we can see to the vascular system beneath the wound.

Assuming a successful diagnosis, treatment poses its own hurdles. Lifestyle modifications are certainly an ongoing challenge in the PAD population where medical advice is seldom followed by patients. For this reason, PAD intervention is often reactive to emergent symptoms. To get ahead of amputation then, general practitioners, podiatrists, and wound care specialists must be proactive in involving their Vascular colleagues. Revascularization is recommended when symptoms cannot be addressed with conservative therapies, making it a viable option for late-stage PAD before CLI sets in. Even when the patient is in CLI and being considered for amputation, it’s not too late to save the limb. The right Vascular Specialist can re-establish flow and restore the limb to health in lieu of amputation.

Despite these positive findings, amputation is still the first-line treatment offered for approximately half of all CLI cases that end in amputation [4]. This disparity is due in part to the simple fact that some patients are not viable candidates for revascularization, but some portion of this represents a gap in detection, diagnosis, and referral.

Success of Amputation Prevention Programs

Management of peripheral artery disease and its complications is complex and involves a diverse medical team to successfully prevent amputation. Dedicated amputation prevention programs, also called limb salvage programs, have been established by many Vascular Specialists around the country to more effectively manage the complexities of PAD care and maximize limb survival. At their core, amputation prevention centers focus on comprehensive vascular screening, imaging, and interventional services for PAD, while actively coordinating with complimentary care providers in wound care, podiatry, infectious disease, endocrinology, and other disciplines as needed.

As a relatively new and innovative development, evidence for amputation prevention programs is limited to single centers, but these centers have boasted tremendous success. One such amputation prevention center in Florida formally reported reducing amputation rates from 29% to 1% over the course of a 5-year period [1]. We’re happy to say that we’ve seen similar levels of success in our own practice at ProVascularMD amputation prevention centers in Southern California. Get in touch to learn more.