CLI Survival Advantage With Amputation Over Angioplasty?

By Mark S. Lesney

The advantages of percutaneous transluminal angioplasty for limb salvage over amputation in patients with critical limb ischemia who are not candidates for open surgery disappeared over time, according to a registry study of more than 300 patients.

In contrast, amputation showed a significant mortality benefit, according to a report by Dr. Spence M. Taylor and colleagues.

PTA is a logical alternative for patients with critical limb ischemia (CLI) who possess physical debilities that most vascular surgeons would consider contraindications to bypass surgery, according to the researchers from Greenville (S.C.) Hospital System University Medical Center.

Using a prospective vascular registry of all cases performed in the medical center's vascular surgery department, researchers identified 314 patients with CLI from 1998 to 2006 who were medically, mentally, or functionally unsuitable for open vascular surgery. Medical impairment was defined as having at least two active clinical diagnoses: dialysis-dependent end-stage renal disease; high-risk coronary artery disease; or chronic obstructive pulmonary disease. Mental impairment was defined as dementia not requiring institutionalization. Functional impairment was defined as homebound ambulatory or nonambulatory transfer only.

A total of 183 patients underwent 206 major limb amputations, and 131 patients underwent percutaneous transluminal angioplasty (PTA) of 148 lower extremities for limb salvage (47 aortoiliac and 101 infrainguinal procedures), according to the report (J. Vasc. Surg. 2007;45:304-11).

The cumulative advantage of maintained independent living status for PTA lasted only 3 months and the ambulation advantage only 12 months. At 2 years, there was no significant difference. However, the median survival time for patients undergoing amputation was 24 months, compared with 14 months for PTA, a statistically significant difference. This survival benefit for amputation was seen by 6 months and maintained until the end of the 3-year follow-up.

After adjustment for possible selection bias, treatment type remained the most clinically significant variable explaining the survival difference. They postulated PTA patients may be exposed to additional stress resulting from the chronic foot wounds associated with CLI. This may have led to poorer long-term survival as the result of this chronic illness and treatment. They stated that PTA in this group of patients "affords very little benefit compared to amputation alone."