Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.
Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation.
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DOI：
10.1016/j.ejvs.2020.06.026
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发表时间：
2020-10
期刊：
影响因子：
--
通讯作者：
Czerniecki JM
中科院分区：
文献类型：
--
作者：
Norvell DC;Czerniecki JM
确定首次血管障碍截肢后12个月内同侧再次截肢的时间、发生率和风险因素，并确定每个截肢水平下风险增加的特定患者亚组。一项回顾性队列研究评价了2004年至2014年期间在VA手术质量改进计划数据库中识别的7187例继发于糖尿病和/或外周动脉疾病（PAD）的首次单侧经跖骨（TM）、经胫骨（TT）或经股动脉（TF）截肢患者。再次截肢定义为任何后续同侧软组织/骨翻修或截肢至更高节段。确定了23个潜在术前风险因素（和9个潜在相互作用）。后向逐步考克斯回归用于识别危险因素。计算发生率和风险比（HR）及95%置信区间（CI）。第一年达到最高水平再截肢的中位时间为33天（四分位距，13-73）。需要至少一次再次截肢的风险为41%（TM）、25%（TT）和9%（TF）。与需要再次截肢相关的风险因素包括慢性阻塞性肺疾病、白色血细胞计数升高、踝臂指数（ABI）异常、血运重建史和酗酒。仅患有糖尿病（HR 1.9; 95% CI 1.4-2.5）、踝臂指数（ABI）评分异常的糖尿病（HR 2.4; 95% CI 1.8-3.2）和肾衰竭（HR 1.7; 95% CI 1.3-2.1）的TM患者再次截肢的风险最大。吸烟的TT截肢者的风险也增加（HR 1.4; 95% CI 1.2-1.6）。该研究确定了原发性愈合失败和需要在TM和TT水平再次截肢的重要风险因素。如果考虑TM截肢，糖尿病患者应谨慎，特别是ABI异常和/或肾衰竭的患者。在TT水平上，吸烟者应谨慎行事。
To identify timing, incidence, and risk factors for ipsilateral re-amputation within 12 months of first dysvascular amputation and to determine specific subgroups of patients at each amputation level that are at increased risk. A retrospective cohort study evaluating 7187 patients with first unilateral transmetatarsal (TM), transtibial (TT), or transfemoral (TF) amputation secondary to diabetes and/or peripheral artery disease (PAD) were identified in the VA Surgical Quality Improvement Program database between 2004 and 2014. Re-amputation was defined as any subsequent ipsilateral soft tissue/bony revision or amputation to a higher level. Twenty-three potential pre-operative risk factors (and nine potential interactions) were identified. A backward stepwise Cox regression was used to identify risk factors. Incidence rates and hazard ratios (HR) with 95% confidence intervals (CI) were computed. The median time to highest level of re-amputation in the first year was 33 (interquartile range, 13–73) days. Risk of requiring at least one re-amputation was 41% (TM), 25% (TT), and 9% (TF). Risk factors associated with requiring re-amputation included chronic obstructive pulmonary disease, elevated white blood cell count, abnormal ankle brachial index (ABI), history of revascularisation, and alcohol misuse. TM patients who had diabetes only (HR 1.9; 95% CI 1.4–2.5), diabetes with an abnormal ankle brachial index (ABI) score (HR 2.4; 95% CI 1.8–3.2), and kidney failure (HR 1.7; 95% CI 1.3–2.1) were at the greatest risk of re-amputation. TT amputees who were smokers were also at an increased risk (HR 1.4; 95% CI 1.2–1.6). This research identified important risk factors for failure of primary healing and need for re-amputation at the TM and TT level. If considering a TM amputation, caution should be exercised in patients with diabetes, in particular those with an abnormal ABI and/or renal failure. At the TT level, caution should be exercised in those who smoke.
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