Infrainguinal Bypass and Amputation on a Par for Patient Survival

A new study comparing the results of infrainguinal bypass (IB) and major amputation (AMP) in limb ischemia patients with severe systemic comorbidities found no difference between the two in the overall number of major adverse events or postoperative length of stay.

Researchers at Brigham and Women's Hospital (Boston, MA, USA) reviewed procedural codes from the 2005-2008 U.S. National Surgical Quality Improvement Program database, using propensity score matching to identify all patients undergoing either IB or AMP. A total of 780 IB patients and 792 AMP patients were identified, with no significant differences among the demographic, preoperative, or anesthetic variables. Patients with systemic or local infections were excluded.

The researchers found that there was no difference in the overall number of major adverse events or postoperative length of stay between the AMP and IB groups. When using risk-adjusted propensity-matched comparison, the researchers found that the IB group had a lower 30-day postoperative mortality than the AMP group (6.5% versus 10%, respectively). Also, IB was associated with significantly higher rates of return to the operating room (27.6% versus 14.1%), as well as a trend toward higher bleeding requiring transfusion (2.1% versus 0.9%). Major amputation, however, had higher rates of pulmonary embolism (0.9% versus 0%) and urinary tract infection (5.2% versus 2.7%). The study was presented at the 64th Vascular Annual Meeting of the Society for Vascular Surgery (SVS), held during June 2010 in Boston (MA, USA).

"Our study shows that the decision to perform infrainguinal bypass or major amputation should depend on well-established predictors of graft patency and functional success rather than presumptions about the perioperative risks associated with the two treatments,” said lead author and study presenter said Neal R. Barshes, M.D., M.P.H, of the division of vascular and endovascular surgery.

High-risk patients with multiple comorbidities are defined as class 4 or 5 by the American Society of Anesthesiologists (ASA); or ASA class 3 with either congestive heart failure (CHF) within 30 days, myocardial infarction (MI) within 6 months, renal failure (serum creatinine higher than 3 mg/dL or dialysis-dependence), dyspnea at rest, or ventilator dependence.

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