title: Endovascular revascularization is associated with a lower risk of above knee amputation than surgical or combined modalities. Analysis of English hospital admissions over a six year period.
abstract: BACKGROUND
  We aimed to determine whether revascularization modality affected risk of an above knee amputation (AKA) in patients with peripheral arterial disease.
  
  
  METHODS
  We used English hospital data and began by determining the number of major amputations and revascularization procedures performed between 1st April 2003- 31st March 2009. We then extracted demographic (age, sex, level of deprivation, treatment location), comorbidity (diabetes, hypertension, hypercholesterolemia, coronary heart disease, ischemic cerebrovascular disease and smoking) and revascularization modality (endovascular/surgical) data. Multi-variate analysis determined the odds ratios of an AKA in relation to previous revascularization attempts (if any).
  
  
  RESULTS
  Over the six year period, there were 25,312 major amputations of which 7544 (29.4%) were linked to a revascularization attempt. Level of amputation was significantly influenced by previous revascularization. Compared to patients not linked to revascularization, those requiring endovascular treatment were less likely to undergo an AKA (OR 0.82; 95% CI 0.75-0.90). Surgical (OR 1.16; 1.07-1.25) and combined endovascular/surgical treatment (OR 1.24; 1.09-1.40) had the opposite effect. Men (0.64; 0.55-0.74) and diabetics (0.44; 0.55-0.74) were less likely to undergo an AKA whereas patients with coronary (1.28; 1.10-1.47) or cerebrovascular (1.90; 1.33-2.71) disease were more likely to have the procedure. Age, deprivation, hypertension, hypercholesterolemia, smoking and geographical location did not influence the level of amputation.
  
  
  CONCLUSIONS
  When a major leg amputation is necessary, the risk of this being carried out above the knee may be lowest after endovascular revascularization attempts and highest after combined endovascular and surgical treatment.
authors.affiliation: Manchester Vascular Centre, Manchester Royal Infirmary, Manchester, UK - naseer.ahmad@cmft.nhs.uk.
authors.forename: Naseer
authors.initials: N
authors.lastname: Ahmad
authors.forename: Neil
authors.initials: N
authors.lastname: Thomas
authors.forename: Paramjit
authors.initials: P
authors.lastname: Gill
authors.forename: Francesco
authors.initials: F
authors.lastname: Torella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D003131:Combined Modality Therapy; D015897:Comorbidity; D016208:Databases, Factual; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects*; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D023821:Limb Salvage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010343:Patient Admission; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects*