Factors associated with in-hospital amputation after revascularization for lower extremity trauma

Abstract

Objectives

While concomitant vascular injury is associated with an increased risk of amputation following lower extremity trauma, risk factors for amputation after attempted revascularization are lesser known. In centers where dedicated vascular traumatic expertise is not available, a lack of guidance regarding high-risk vascular trauma may limit efforts to appropriately triage and transfer patients to a higher level of care. We identified factors associated with in-hospital amputation after revascularization for isolated lower extremity trauma.

Methods

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) is a multicenter, prospectively maintained database containing deidentified traumatic admissions data for over 900 trauma centers in the United States. From 2017 to 2021, ACS TQIP was queried for adult patients undergoing arterial revascularization following isolated lower extremity trauma. Injury-related variables were derived from structured data fields, Injury Severity Scores, and Abbreviated Injury Scores. The primary endpoint was post-revascularization in-hospital lower extremity amputation. Univariate and multivariate logistic regression of demographic data, medical history, and injury-related variables were performed to identify factors associated with post-revascularization amputation.

Results

Of 5669 patients undergoing revascularization, 10.2% underwent amputation a median 8.31 days after their surgical procedure. Most revascularizations were done via open surgical approach (81.9%), followed by endovascular (13.8%) and hybrid (4.3%) methods. Amputated patients were older (39.5 vs 35.6 years, p < 0.001, Table 1) and more likely to have a preoperative history of peripheral arterial disease (1.4% vs 0.6%, p = 0.017). On multivariate logistic regression, blunt mechanism (OR 4.80, p < 0.001, Table 2), popliteal arterial injury (OR 2.11, p < 0.001), and concurrent bony injury (OR 2.03, p < 0.001) were independently associated with amputation.

Conclusions

In the multicenter American College of Surgeons Trauma Quality Improvement Program, the overall rate of post-revascularization amputation in patients with isolated lower extremity trauma was 10.20%. Amputation risk was higher in patients with advanced age and comorbidity, suggesting that triage for revascularization already incorporates an evaluation of patient frailty. In multivariate analysis, blunt mechanism of injury, popliteal artery injury, and bony injury were independently associated with amputation. Each additional hour between admission and revascularization was associated with greater amputation risk, highlighting the importance of efforts to expediently and appropriately triage patients at with high-risk injuries to optimize limb salvage outcomes.