I. Dawson

Late outcomes of limb loss after failed infrainguinal bypass

PURPOSE Most reports regarding infrainguinal bypass surgical procedures demonstrate benefits well but pay less attention to adverse outcomes and consequences of failure for the patient. For a wider scope of infrainguinal bypass surgical procedures, we evaluated patient-oriented outcomes of limb loss occurring after failed infrainguinal bypass operations. METHODS Eighty-one patients with vascular amputations were identified in a retrospective study. Follow-up was complete with a mean of 3.6 years. Life-table and multivariate analyses were used to assess factors influencing the desired outcome goals of rehabilitation. Mortality rates, social function, risk of contralateral amputation, and the ability to walk were used to measure the late outcome. RESULTS The long-term survival rate was poor (72% at 1 year; 53% at 3 years) and was not related to traditional risk factors for atherosclerosis. Moreover the risk for contralateral amputation was 10% per year. One year after amputation 81% (47 of 58) of the surviving amputees were walking independently, and 73% (42 of 58) were living at home, 32 with their spouse. At 3 years these results were 73% (27 of 37) and 78% (29 of 37), respectively. In addition, the level of self-care changed significantly (p < 0.001) after amputation. Advanced age (older than 65 years), self-care performance, and living with someone were important predictors of late outcome. CONCLUSIONS It is possible for a high percentage of patients with vascular amputations to return home successfully, either walking or in a wheelchair. Moreover this result can be predicted based on preoperative clinical variables. These data may be helpful to guide fitting of prosthetic devices, planning of discharge home, and use of health care resources.

Ruptured popliteal artery aneurysm. An insidious complication

OBJECTIVES To evaluate the incidence and clinical presentation of ruptured popliteal aneurysms. METHODS The records of 89 consecutive patients, all males, seen between 1958 and 1995 with 124 arteriosclerotic popliteal aneurysms were reviewed retrospectively. Most aneurysms were symptomatic (69/124; 55.6%). In six cases (6/124; 4.8%) a rupture was present. RESULTS There was a wide range in primary diagnosis varying from deep venous thrombosis to peroneal nerve palsy. In all cases primary reconstructive surgery was performed. No primary or secondary amputations were necessary. Surgical outcome was good in four cases. In the remaining cases one patient suffered from a permanent peroneal nerve palsy and one from non-disabling claudication. Review of the literature showed a rupture incidence of 2.5% (range 0-16%) and amputation rates as high as 100%. CONCLUSION An acute rupture of a popliteal aneurysm is rare. Although the clinical presentation can be non-specific, this possibility must be especially taken into account when dealing with older male patients presenting with signs and symptoms of generalised atherosclerosis and non-specific pain in the popliteal region.

Late nonfatal and fatal cardiac events after infrainguinal bypass for femoropopliteal occlusive disease during a thirty-one—year period

PURPOSE AND METHODS In patients with peripheral vascular disease the complications of associated coronary artery disease have always been a leading cause of morbidity and mortality. Therefore we evaluated the risk for late cardiac morbidity and mortality in 376 consecutive patients after infrainguinal bypass. Follow-up was complete for 373 patients (99.3%) with a mean follow-up period of 5.9 years. After operation all but four patients were treated with lifelong warfarin (Coumadin therapy.) RESULTS During follow-up 129 patients (34.3%) had 183 late cardiac events. Of these patients, 79 (61.2%) died of late cardiac events and 13 (10.0%) required either coronary angioplasty or bypass. The risk of late cardiac events was 34% at 5 years and increased to 56% at 15 years. Multivariate analysis demonstrated that age, cardiac disease, and impaired renal function at the time of operation were associated with an increased risk of cardiac events during follow-up. Independent predictors of cardiac death were age, cardiac disease, hypertension, diabetes, and impaired renal function. Morbidity and mortality was particularly high in patients with critical ischemia. The subset of patients with claudication had a life expectancy that appeared to be similar to that of a matched sample of the normal population. CONCLUSIONS Our findings clearly demonstrate that some patients undergoing infrainguinal bypass are at high risk for late cardiac events of which many are fatal, whereas others may have an almost normal life expectancy. Most important, the occurrence of cardiac events may be predicted by simple and readily obtainable clinical variables at the time of the initial infrainguinal bypass procedure. Because these events were related to late cardiac death, this may be the key for angiographic evaluation and possible prevention of cardiac death.

Ischemic and hemorrhagic stroke in patients on oral anticoagulants after reconstruction for chronic lower limb ischemia.

Background and Purpose Information on the long-term fate of patients with chronic lower limb ischemia is limited. We investigated the long-term risk of the first ischemic and hemorrhagic cerebral stroke in patients on long-term anticoagulant therapy after reconstruction for chronic limb ischemia. Methods In a retrospective study, 376 consecutive patients were seen at regular intervals according to a standard protocol. Only 3 (0.7%) were lost during follow-up (mean duration, 5.9 years). Anticoagulation was with coumarin derivatives followed by prothrombin times periodically. Primary end points were ischemic and hemorrhagic cerebral stroke events, which were confirmed by CT scan, autopsy, or operation in 85% of the cases. Major vascular events were analyzed as a composite secondary end point. The influence of several clinical variables on these outcome events was evaluated in univariate and multivariate analyses. Results Thirty-nine patients (10%) had 41 stroke events (23 ischemic, 18 hemorrhagic); 22 of these patients (56%) died from stroke. The cumulative ischemic stroke risk was 5% at 5 years and 12% at 15 years. Prior myocardial infarction was the only independent predictor (relative risk [RR], 3.1; P<05). The cumulative hemorrhagic stroke risk was 3% at 5 years and 17% at 15 years. Systolic hypertension (RR, 4.8; P<.01) and insulin-dependent diabetes mellitus (RR, 5.4; P<.01) were significant and independent predictors. The risk for a major vascular event was 29% at 5 years and increased to 56% at 15 years. Independent predictors were advanced age (RR, 1.4; P<.005), insulin-dependent diabetes (RR, 2.2; P<.005), and prior myocardial infarction (RR, 1.8; P<.01). Conclusions Patients with chronic lower limb ischemia, notably those with prior myocardial infarction, are at high risk for ischemic stroke. Those with systolic hypertension or insulin-dependent diabetes mellitus are at high risk for hemorrhagic stroke. (Stroke. 1993;24:1655-1663.)

Vascular morbidity and mortality during long-term follow-up in claudicants selected for peripheral bypass surgery

OBJECTIVES To identify claudicants at high risk (and low risk) of late vascular morbidity and mortality after peripheral bypass surgery. DESIGN Prospective cohort study with mean follow-up of 8.6 years. PATIENTS One-hundred and fifty-five claudicants selected for peripheral bypass surgery. Only three patients were lost to follow-up. End points were major vascular events, additional interventions, all-cause mortality, and functional outcome. RESULTS Major vascular events occurred in 59 patients. Life-table analysis revealed an annual risk increase of 3.5%. Strong predictors were hypertension (hazard ratio (HR) 2.7; 95% confidence interval (CI) 1.5-4.8), diabetes (HR 2.4; 95% CI 1.0-5.4) and cardiac disease (HR 2.2; 95% CI 1.2-4.0). Sixty patients needed additional interventions with a highest incidence (17%) in the first year, and thereafter 2.8% each year. None of the known risk factors were associated with an altered incidence of interventions. Approximately 3.5% of patients died per year compared with 2% per year in the control group. Prominent high-risk factors for mortality were cardiac disease (HR 3.3; 95% CI 1.8-6.0) and diabetes (HR 3.0; 95% CI 1.5-7.1). CONCLUSION Major vascular events and additional interventions are common and serious in claudicants. However, it is possible to select low-risk patients in which peripheral bypass surgery is justified.