A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery

Abstract

Background: Percutaneous transluminal angioplasty (PTA), although not the traditional therapy, seems to be a safe alternative for patients with critical limb ischemia who are believed to be unsuitable candidates for open surgery. However, the efficacy of PTA in this setting has not been analyzed. The purpose of this study was to compare the outcomes of PTA for limb salvage with outcomes of major limb amputation in physiologically impaired patients believed to be unsuitable for open surgery.

Methods: From a prospective vascular registry, 314 patients (183 underwent amputation, and 131 underwent complex PTA for limb salvage) were identified as physiologically impaired or unsuitable for open surgery. This was defined as having at least one of the following: functional impairment (homebound ambulatory or transfer only), mental impairment (dementia), or medical impairment (two of the following: end-stage renal disease, coronary artery disease, and chronic obstructive pulmonary disease). Patients undergoing PTA were compared with patients undergoing amputation by examining the outcome parameters of survival, maintenance of ambulation, and maintenance of independent living status. Parameters were assessed by using Kaplan-Meier life-table curves (log-rank test and 95% confidence intervals [CIs]) and hazard ratios (HRs) from the Cox model.

Results: PTA resulted in a 12-month limb salvage rate of 63%. Thirty-day mortality was 4.4% for the amputation group and 3.8% for the PTA group. After adjustment for age, race, diabetes, prior vascular procedure, dementia, and baseline functional status, PTA patients had significantly lower rates of ambulation failure (HR, 0.44; P = .0002) and loss of independence (HR, 0.53; P = .025) but had significantly higher mortality (HR, 1.62; P = .006) than amputees. However, when life tables were examined, the maintenance of ambulation advantage lasted only 12 months (PTA, 68.6%; 95% CI, 59.6%-77.7%; amputation, 48%; 95% CI, 40.4%-55.5%) and was not statistically significant at 2 years (62.2% [95% CI, 48.8%-71.5%] and 44% [95% CI, 35.8%-52.2%], respectively). Maintenance of independent living status advantage lasted only 3 months, with no statistically significant difference at 2 years (PTA, 60.5%; 95% CI, 45.4%-75.6%; amputation, 52.6%; 95% CI, 40.4%-64.9%). Although mortality was high in both cohorts, patients who underwent amputation had a survival advantage for all time intervals examined (at 2 years: PTA, 29%; 95% CI, 19.9%-38.1%; amputation, 48.1%; 95% CI, 39.2%-56.9%).

Conclusions: Patients who present with critical limb ischemia and physiologic impairments that preclude open surgery seem to have comorbidities that blunt any functional advantage achieved after PTA for limb salvage. PTA in this setting affords very little benefit compared with amputation alone.