The Number of Revascularization Procedures is Associated With Final Amputation Level for Chronic Limb-Threatening Ischemia

Abstract

Background

The relationship between the number of revascularization procedures and the level of major lower extremity amputation in chronic limb-threatening ischemia (CLTI) remains unclear. We aim to determine whether the revascularization frequency is associated with the level of amputation and whether procedural burden influences postoperative outcomes.

Methods

We performed a retrospective chart review of 252 patients who underwent major lower extremity amputations for CLTI from 2014 to 2022. The primary outcome was the association between revascularization frequency and amputation level, categorized into above-knee amputation (AKA) or non-AKA (through-knee and below-knee). Secondary outcomes included the association of revascularization level and type (open, endovascular, or hybrid) with AKA risk. Other outcomes were postoperative complications, readmission, reamputation, and mortality. Multivariable logistic regression adjusted for age, diabetes, and disease level.

Results

The mean age was 55.9 years, with 61.9% male patients, and 58.3% identifying as Black. Most had hypertension (86.5%) and diabetes (62.3%). Among the cohort, 45% of the patients had no revascularizations. 47.6% underwent 1-2 procedures, and 7.5% underwent three or more procedures. Undergoing ≥3 revascularizations was significantly associated with increased odds of above-knee amputation (AKA) (OR: 6.33, 95% CI: 2.00-20.00, P = 0.002). Disease level and type of revascularization were not significantly associated with amputation level. There were no significant differences in postoperative complications, readmissions, reamputations, or mortality between AKA and non-AKA groups.

Conclusion

Patients undergoing three or more revascularization procedures were significantly more likely to undergo an AKA, suggesting a threshold effect where additional interventions may diminish patient benefits.