Chronic Limb-Threatening Ischemia: Revascularization Versus Primary Amputation
Nypaver TJ. Chronic Limb-Threatening Ischemia: Revascularization Versus Primary Amputation. Curr Surg Rep 2021; 9(6).
Current Surgery Reports
Purpose of Review: This discussion will review and investigate the indications for amputation, specifically for primary amputation (amputation performed without an attempt at a limb salvage revascularization procedure) in lower extremity chronic limb-threatening ischemia (CLTI). We will further investigate the results of lower extremity revascularization and discuss the factors that are associated with an adverse outcome after revascularization. In this way, we will define when primary amputation may be warranted or, minimally, should be strongly considered over what may be overtly futile attempts at limb salvage procedures.
Recent Findings: The incidence of amputation, after two decades in which amputation rates have declined, has recently been on the rise, related to an increase in diabetic-associated amputation. Endovascular options have extended treatment for those high-risk patients with CLTI. Despite this, there is little comparative data regarding the appropriate selection for the initial revascularization attempt. Revascularization procedures do fail and factors associated with adverse outcome are being continuously elucidated and re-affirmed, including patient comorbidities (end-stage renal disease, frailty, dementia), wound assessment (wound, ischemia, foot infection classification), and anatomic patterns of the occlusive disease. Indications for primary amputation include major tissue loss, non-ambulatory status and declining functionality, un-reconstructable vascular occlusive disease, and situations in which either the risks exceed the benefit or there is limited benefit due to high probability of an adverse outcome.
Summary: Primary amputation remains an important alternative in the management of CLTI. Further staging and classification of variables and of the disease pattern will hopefully allow for a more evidence-based decision-making process and further define the role of primary amputation.