The majority of patients undergoing major leg amputations for chronic limb-threatening ischemia do not undergo revascularization prior to amputation and have increased mortality

Background: Many patients with chronic limb-threatening ischemia (CLTI) undergo lower extremity amputations, and recent data have shown that revascularization operations are not offered to many patients with CLTI, who may benefit from such operations. This study aimed to evaluate the proportion of patients with CLTI who undergo major lower extremity amputation without prior revascularization attempts and to assess postoperative outcomes among all patients undergoing major lower extremity amputations, using data from a large national database. Methods: The TriNetX database was queried for all peripheral arterial disease patients from 2000 to 2020 who underwent first-time major lower extremity amputation (at either the below the knee level or above the knee level). This sample was divided into two cohorts: No history of interventions before amputation (group I) vs history of single or multiple vascular interventions before amputation (group II). The primary outcome was mortality at 1 and 3 years postoperatively. Secondary outcomes included myocardial infarction, pulmonary embolism, stroke, deep vein thrombosis, heart failure, dysrhythmias, and major adverse cardiac events assessed at 30 days and 1 year. Group II was further divided into subgroups based on the number of revascularization attempts: 0, one to four, five to eight, and more than eight. Univariate analysis was performed via the t test and the χ² test. Multivariable logistic regression was performed to assess the association of revascularization history with mortality. Significance was set at a P value of less than .05. Results: A total of 5328 patients met inclusion criteria. Group I included 3110 patients and group II included 2328 patients. Group I patients were more likely to be younger, non-White, and have a history of hypertension, hyperlipidemia, heart failure, chronic obstructive pulmonary disease, and coronary artery disease. Group I demonstrated increased mortality at both 1 years (32% vs 28.1%; adjusted P = .005) and 3 years (45.6% vs 40.4%; adjusted P < .001) postoperatively. Furthermore, these patients experienced more major adverse cardiac events (12.4% vs 10.4%; P = .021) at the 30-day timepoint. Multivariable-adjusted analysis confirmed that history of revascularization was associated with a decreased risk of 1-year mortality (adjusted odds ratio [AOR], 0.82; 95% confidence interval [CI], 0.73-0.94; P = .003) and 3 -year mortality (AOR, 0.78’ 95% CI, 0.70-0.88; P<.001). Subgroup analysis demonstrated lower mortality risk with greater number of interventions (AOR, 0.81 [95% CI, 0.72-0.92]; AOR, 0.67 [95% CI, 0.53-0.86]; and AOR, 0.66 [95% CI, 0.42-1.05]). Conclusions: Patients who undergo revascularization attempts before major lower extremity amputation are less likely to experience mortality at 1 and 3 years postoperatively. These patients also received the best medical therapy more often, and the number of revascularizations before amputation correlated with the duration of limb preservation before ultimate amputation.