Amputations in peripheral vascular disease
(Portuguese PDF version)

Nelson De Luccia*

*Professor of Vascular Surgery, Department of Surgery, Universidade de São Paulo (USP), São Paulo (SP), Brazil.

J Vasc Br 2004;3(3):179-80

The initial procedures of the 36th Brazilian Congress of Angiology and Vascular Surgery have already started and, again, the same question has arisen: how to proceed with the free papers?

• Can amputations be avoided or are they an inevitable outcome in elderly populations affected by degenerative arterial disease and/or diabetes and neuropathy?

• Is revascularization effective to prevent amputations or does it simply postpone the procedure, often increasing morbidity and mortality and even compromising the amputation level, with a negative impact on the ischemic and/or infectious presentation?
  It is natural that flaws will still occur and only time will be able to show the best solution.

• Is the quality of life following an amputation comparable to or better than that following revascularization without amputation, considering that several individuals in whom amputation is not performed are never able to walk again due to the consequences of ischemic disease or other effects of old age?

There are few medical reports that are as clear concerning pathophysiological aspects as that of Kunlin when describing the reversal of ischemia in the extremity following the performance of the first saphenous vein graft:

Nous avon tente notre première greffe chez um artéritique grave, age de 54 ans, ne pouvant plus travailler depuis un an , ayant déjà subi la sympathectomie lombaire et l'artérectomie fémorale , l'amputation du gros orteil. Ce malade soufrait de plus em plus surtout depuis l'apparition d'edème et d'ulcération gangréneuses du dos du pied gauche. Le 3 juin1948 nous avon uni l'artère fémorale commune à l'artère poplitée par l'intermédiaire d'um segment veineux saphénien de 26 cm ½. La transformation du malade a été immédiate. Lês ulcération ont guéri on deux semaine. Lê douleurs ont disparu dês l'operation. Lê pied qui était froid et violacé, dont la peau était squameuse est redevenu normal. Le pouls pédieux est réapparu. Les oscillations ont passé de 0, à la cheville et au mollet, à ¾ et 4. La marche se fait sans aucune douleur¹.

After more than 50 years, this is still true.

In the article by Leite et al., published in the current issue of J Vasc Br, in just over 1 year, more than 300 amputations were performed in one single service. It is an honest and courageous report, in which the reader's attention is drawn to facts such as the high number of transfemoral amputations (76%), the low proportion of revascularization procedures in the two studied groups (only 25% for unilateral and bilateral amputations) and the 50% mortality in the bilateral amputation group.

There is no doubt that these data reflect the severity of the cases treated; however, despite such a high number of primary amputations, the inclusion criterion was the presence of trophic lesions in the toes or forefoot and resting ischemic pain. According to consensus recommendations, amputation is only indicated in extremities presenting gangrene in the forefoot region, or more extensive gangrene in non-functional extremities.² Any criterion outside this range is subjective and can only be expressing the orientation of the Service regardless of the conditions of the population in a given geographical area when seeking care at the hospital. It should be noted that the mean age of the population in the study is 65 years.

Will aggressive revascularization of myocutaneous flaps inevitably result in amputation? It is of course that free flaps and tissue transfer constitute exceptional procedures, but what are aggressive revascularizations? Are distal derivations for the fibular artery or foot arteries (dorsal, foot sole) included in this definition?

Another issue that receives little attention when the scarring of amputations is analyzed, besides tissue vitality, is technical expertise on the part of the surgeon. Many transtibial procedures have complications due to technical problems. And revascularization, especially "aggressive" revascularization, depends to a large extent on technical training.

It is not surprising that the rehabilitation of patients submitted to bilateral transfemoral amputation is not simple. The effort to preserve the knee joint, especially in elderly populations, should never be underestimated, and is a precondition for rehabilitation. In 1968, in a now classical report concerning elderly patients submitted to amputation, Pedersen states:" It is apparent that the current problem of the geriatric amputee is not primarily one of prosthetic components, prosthesis design, fitting and alignment, or gait training. The current problem of the geriatric amputee is preservation of the knee joint."³

The rate of 0.31 transtibial amputations for each transfemoral amputation is one of the lowest ever reported, and should no doubt be reconsidered by the service.⁴

The balance between attempting revascularization or indicating amputation is not always easy to achieve, but Medicine is subtle. Amputations are an excellent choice if performed as reconstructive procedures following precise indications. They can save the lives of patients and result in rehabilitation, ability to walk and excellent quality of life. But these results are still below those of successful revascularization procedures.⁵

The group reporting their results deserves congratulations for having tackled the current issue of amputations. However, we will save further congratulations for their report on a new case series - perhaps in 2005 - in which the number of primary amputations will be decreased, the number of revascularization procedures will be increased, and the rate of transtibial to transfemoral amputation will be reversed.

REFERENCES

1. Kunlin J. Le traitement de l'artérite oblitérante par la greffe veineuse. Soc Fr de Cardiologie; 1948.

2. Rutherford R, Baker J, Ernst C, Johnston W, Porter J, Ahn S, Jones D. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997:26:517-38.

3. Pedersen H. The problem of the geriatric amputee. Artificial Limbs 1968;12:i-iii.

4. TASC. J Vasc Surg 2000;31:S26.

5. Albers M, Fratezi A, De Luccia N. Assessment of quality of life of patients with severe ischemia due to infrainguinal arterial occlusive disease. J Vasc Surg 1992:16:54-9.