On follow-up after hospital discharge and rehabilitation, patients tend to report relatively high scores on subjective quality-of-life (QoL) measures. A 2008 study confirmed thatpredictorsofdecreasedQoLscoresincludesymptomsofdepression,decreasedmobility with prosthetics, number of prosthetic problems, increasing number of comorbidities, and less social support and daily social activity. Among these factors, depression was found to have the single largest impact on reported QoL.24 Further study on depression in amputees found a rate of 17–20% at 1–3 years after surgery, compared to a 23% rate prior to admission and 2% at discharge. The post-surgical depression was found to be associated with baseline depression at admission and significant comorbidities, but not with length of hospital stay, wearing of the prosthetic, or dysvascular disease as the cause of amputation.25 The therapy team can make the greatest impact on the quality of life of amputees by ensuring adequate mental health resources are available to the patient.

Regrettably, the morbidity and mortality profile of patients who have undergone major limb amputation is poor. Aggregate data from the TASC II study demonstrated that at 2 years after BKA, only 40% of patients were found to be fully mobile. Another 15% had undergone conversion to AKA, 15% required a contralateral amputation, and 30% were dead.3 A series of 954 amputation from Beth Israel Deaconess found a median survival after AKA of 20 months, and 52 months after BKA; the presence of diabetes mellitus as a comorbidity showed a significant difference of survival at 60 months on the Kaplan-Meier curve of 30%, as opposed to 60% in non-diabetics.26 Data from the Netherlands showed a 62% survival after amputation at 1 year, which dropped to 50% at 2 years and 29% at 5 years.27 In a VA patient retrospective, a 7 year survival rate of 39% was noted; major causes of death in amputees were found to include congestive heart failure, myocardial infarction, respiratory failure, disseminated cancer, overwhelming sepsis, stroke, and renal failure.28 Additional factors contributing to early mortality post-amputation in a West Virginia case series included advanced age, low albumin levels, undergoing an AKA, and the lack of previous cardiac intervention.29 A rate of BKA to AKA conversion of 12–17% was reiterated in the two series from the Veterans Administration and the Netherlands.27,28 Mortality within the first decade after amputation is significant; the etiology of death usually is the result of underlying medical issues that contributed to the need for amputation.

With the proper attention of a vascular surgeon and a multidisciplinary team, an amputation does not have to signify the failure of treatment. Rather, it should be seen as the first step toward functional recovery and regaining a quality of life comparable to the patient’s pre-pathologic state. In many cases, amputation surgery may be preferable to extended distal bypass or multiple revisions of a below-knee bypass if the support infrastructure is available post-operatively. Continuing advances in prosthetic technology have the potential to improve patient outcomes in terms of energy expenditures, recovery of ambulatory ability, and gait improvement. It is incumbent on the vascular surgeon to remain actively engaged in the post-operative care of the amputee.

References

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Part XI

Vascular Malformations