Amputation and mortality: It is time to discuss the obvious

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J A Mustapha

An amputation due to critical limb ischaemia is directly associated with loss of function and death, writes J A Mustapha, Wyoming, USA.

Amputation. A common term we have been using for centuries to describe the loss of a limb. When people most think of amputation, they envision young patients who have undergone a traumatic amputation due to accident or war that are rehabilitated and go on to live a functional life. But ischaemic amputation, which is a major epidemic today, lends a different perspective to the patient and his/her family.

An amputation due to critical limb ischaemia is directly associated with loss of function and death. The TASC II update in 2007 showed that after amputation, 25% of patients are dead within one year and 20% of those patients who survive continue to struggle with the disease.1 The majority of patients over 75 years of age who receive an amputation do not ever walk again. Amputation is a very traumatic event that impacts the life of the patient and family in a profound and critical way.

Historically, much awareness has focused on many other less deadly diseases that have 10% of the mortality in comparison to critical limb ischaemia, including breast cancer and colon cancer. A patient diagnosed with breast cancer has an almost 90% chance of surviving five years. A patient who is diagnosed with colon cancer has a 65% chance of surviving five years.2 Critical limb ischaemia patients who undergo amputation have a less than 20% chance of five-year survival. So let us discuss the obvious. There is a clear and present lack of critical limb ischaemia awareness among all healthcare providers. A disturbing 2012 publication by Goodney et al showed that 54% of major ischaemic amputations were performed on patients without a prior diagnostic angiography or intervention during the year prior to the amputation.3

I feel strongly that patients and their families need to learn there are options today that can prevent amputation. Avoiding amputation, in most cases, can delay or prevent death. Because of the serious consequences of amputation, I feel compelled to describe the course that critical limb ischaemia tends to run through. Due to this aggressive course, frequent and regular surveillance must occur to achieve sustainable amputation-free survival. As shown in Figure 1, the majority of patients diagnosed with critical limb ischaemia without their course of therapy adjusted are likely to either receive a major amputation within 12 months or, worse yet, die. Whereas, in Figure 2 the same patients, but with an adjusted course of critical limb ischaemia therapy, can experience completely different outcomes. The majority of them are alive and without a major amputation at 12 months. It is time for us to take action, educate others and ourselves about the seriousness of this illness, and not allow a single amputation to take place without a detailed vascular work up and exhaustive attempts at revascularisation. Consider joining the Critical Limb Ischemia Global Society (www.cliglobalsociety.org) whose awareness and advocacy efforts are aimed at raising public, patient and health professional awareness of treatments to prevent unnecessary amputations.

J A Mustapha is director of Cardiovascular Research, Metro Health University of Michigan Health, Wyoming, USA. He is also clinical associate professor of Medicine, Michigan State University College of Osteopathic Medicine, East Lansing, USA.

References

  1. Jaff MR et al. An update on methods for revascularization and expansion of the tasc lesion classification to include below-the-knee arteries: a supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC Steering Committee. Ann Vasc Dis. 2014; 8(4): 343–57
  2. The surveillance, epidemiology, and end results (seer) program of the national cancer institute (http://seer.cancer.gov/statfacts/
  3. Goodney PP et al. Circ Cardiovasc Qual Outcomes. 2012; 5(1): 94–102