John Phair

Statin use and other factors associated with mortality after major lower extremity amputation

Objective: Above‐knee amputations (AKAs) and below‐knee amputations (BKAs) are associated with high postoperative mortality rates. In this study, we examined factors associated with 30‐day, 90‐day, and 1‐year mortality in patients who underwent a major lower extremity amputation. Methods: We queried a prospectively collected institutional database for all patients who underwent AKA or BKA with primary or secondary closure, during a 5‐year period, between November 2009 and November 2014. Predictors of 30‐ and 90‐day mortality were determined by multivariable logistic regression, and risk indexes for 1‐year mortality were determined with Cox proportional hazards model. Results: We identified 811 patients who underwent AKA (n = 325) or BKA (n = 486). The 30‐day mortality was 8.4% (AKA, 13.5%; BKA, 4.9%; P < .001) and 90‐day mortality was 15.4% (AKA, 24.3%; BKA, 9.45%; P < .001). Predictors of 30‐day mortality included AKA (odds ratio [OR], 3.09; 95% confidence interval [CI], 1.76‐5.53), emergency operation (OR, 2.86; 95% CI, 1.56‐5.14), chronic obstructive pulmonary disease (OR, 3.09; 95% CI, 1.07‐7.81), end‐stage renal disease (ESRD) on hemodialysis (HD; OR, 2.35; 95% CI, 1.24‐4.33), and chronic kidney disease stages 3 (OR, 1.84; 95% CI, 1.00‐3.37) and 4 (OR, 2.33; 95% CI, 1.01‐4.98). Predictors of 90‐day mortality included age (OR, 1.02; 95% CI, 1.00‐1.04), ESRD on HD (OR, 2.56; 95% CI, 1.55‐4.22), AKA (OR, 2.61; 95% CI, 1.70‐4.05), history of coronary artery bypass grafting (OR, 2.04; 95% CI, 1.06‐3.87), and medium‐intensity or high‐intensity statin (OR, 0.46; 95% CI, 0.29‐0.73). One‐year survival for the overall cohort was 73.7% (95% CI, 70.8%‐76.8%). Predictors of 1‐year mortality included AKA (hazard ratio [HR], 2.07; 95% CI, 1.54‐2.77), coronary artery bypass grafting (HR, 1.57; 95% CI, 1.07‐2.32), age >70 years (HR, 1.39; 95% CI, 1.02‐1.88), gangrene (HR, 1.44; 95% CI, 1.07‐1.94), ESRD on HD (HR, 1.96; 95% CI, 1.42‐2.70), chronic obstructive pulmonary disease (HR, 2.54; 95% CI, 1.52‐4.25), Caucasian race (HR, 1.62; 95% CI, 1.18‐2.22), history of open lower extremity revascularization (HR, 0.71; 95% CI, 0.51‐1.00) and undergoing bilateral amputations (HR, 2.10; 95% CI, 1.06‐4.15). In the year after amputation, medium‐intensity statin (HR, 0.64; 95% CI, 0.47‐0.87) and high‐intensity statin (HR, 0.56; 95% CI, 0.33‐0.95) conferred a mortality benefit. Low‐intensity statins did not confer protection from mortality. At 1 year after amputation, only 44.7% of patients were receiving appropriate statin therapy. Conclusions: AKA and BKA have historically been associated with high mortality rates. Medium‐intensity and high‐intensity statin therapies were associated with a mortality benefit at 1 year. We have identified initiation of statin therapy in this high‐risk population as a gap in patient care.

Blast-Cell Arterial Embolus in Acute Myelogenous Leukemia

The link between coagulatory dysfunction in acute leukemias is well known, with patients having an increased risk of bleeding as well as thrombosis. Arterial thrombosis is particularly rare in this population however with only a few reported cases in the literature. We report the case of acute arterial occlusion secondary to a leukoblastic embolus causing limb-threatening ischemia in a patient with acute myelogenous leukemia. The patient was successfully treated surgically by open superficial femoral artery thrombectomy, common femoral endarterectomy with patch angioplasty, and percutaneous tibial embolectomy.

Venous status ulcers due to congenital agenesis of the inferior vena cava in a 16-year-old male

We report a case of agenesis of the infrarenal inferior vena cava in a 16-year-old male presenting with venous stasis dermatitis and ulceration in the gaiter region bilaterally. Duplex imaging was performed revealing absence of infrarenal inferior vena cava and iliofemoral venous system. Magnetic resonance venography then confirmed the above findings along with revealing extensive lumbar and pelvic collateralization. This patient’s condition has been successfully managed conservatively with compression therapy and wound care. This case is a rare example of a congenital malformation of the inferior vena cava and represents the only reported case with presenting symptoms of venous stasis ulceration in a pediatric patient.