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Revascularization versus amputation for elderly patients
SEPTEMBER 1995, VOL 62, NO 3 ELDER CARE
Revascularization versus amputation for elderly patients
P
eripheral and coronary vascular diseases are common in the West; both become clinically important in the latter decades of life, and both are different clinical manifestations of atherosclerosis. The effects of coronary atherosclerosis usually are felt first, with significant mortality due to myocardial infarctions, disabling angina, or ischemic cardiomyopathy. The elderly patient presenting with peripheral vascular disease tends to have a limb salvage situation and significant coexisting illness. The concept of revasculaxization versus primary amputation is a microcosm of the dilemma medicine faces in the nineties. Today’s geriatric patients require costly and time-consuming care and management of their medical problems, but health care providers are under increasing pressure from administrators to minimize patients’ hospital care and costs. Decisions about revascularization or primary amputations in elderly patients can be analyzed carefully on medical and economic grounds, and the decisions need to be individualized. Surgeons depend on perioperative nurses’ complete assessments of patients’ psychosocial statuses as the initial and major determinants of which surgical management option to undertake. Surgeons also depend on perioperative nurses to maximize patients’ ambulatory capacities postoperatively and prevent complications. This is a team approach to patient care.
MEDICAL CONSIDERATIONS Several arguments can be made for primary revascularization or for primary amputation. Revascuhnzafion. Proponents of revascularization base their position on the basic concept of limb preservation because of the attendant benefits of ambulatory ability, sensate protectiveness, and lack of increase in postoperative ambulatory energy expenditure. Limb salvage rates with revascularization actually exceed graft patency rates by 15% to 20%, indicating that limbs may continue to be functional without grafts after the presenting clinical problems (eg, ulcer, gangrenous toes) have resolved (Figure l).’ Five-year patient mortality is high (ie, 35% to 50%)in true limb salvage situations, but the majority of patients (ie, 70% to 80%) can expect to be ambulatory on their salvaged limbs until death.’ Proponents acknowledge the increased mortality of revascularizations in the elderly but note the same mortality rate increase for major amputations as well. They challenge the concept that failed revascularizations lead to higher anatomic levels of amputation than clinically expected and note that increased familiarity and experience with complex distal bypasses (Figure 2 ) has allowed limb salvage attempts in all but a T J BUNT, MD, FACS, is professor of surgery, division of vascular surgery, Lorna Linda (Califl University Medical Center. 433 AORN JOURNAL
small number of patients. Amputation. Proponents of primary amputation base their arguments on the concept of shortened hospital stays, which may translate to lower costs. The proponents also call attention to the increased morbidity and mortality associated with amputations performed for failed revasculari~ations.~ Some institutions have demonstrated equivalent or decreased mortality rates for primary amputations in the elderly. Finally, proponents cite high rates of postoperative prosthetic ambulatory capacity and suggest that early rehabilitation frequently is obtained! It should be noted that such studies have emanated from highly specialized academic centers, are not necessarily applicable to health care in the community, and cannot be readily extrapolated to elderly patients, who less commonly rehabilitate to prostheses. BASIC CONSIDERATIONS Whichever management route is chosen, the medical histories of patients in limb salvage situations (eg, gangrene, ischemic ulcer, rest pain) always must be considered in the decision-making process. The possibility of limb salvage is decreased with increasingly distal and/or repeat attempts at revascularization, and expected long-term survival is decreased in patients with diabetes and those in nursing homes. Thus, the decision for limb amputation or preservation must be made within the confines of limited patient survival and,
SEPTEMBER 1995, VOL 62, NO 3
therefore, may be considered as palliation of the quality of remaining life. Table 1 outlines the basic considerationsthat must be included in an algorithm for patient management.
COMPARATIVE MORBIDITY AND MORTALITY Advanced patient age generally is recognized as an increased risk for all categories of peripheral vascular surgery. This has been borne out by numerous studies and is best exemplified by the extensive Cleveland MetropolitanVascular Registry, in which overall mortality for femoropopliteal/distalrevascularization increased from 2.2% for patients <75 years of age to 6.7% for patients >75 of age, and amputation mortality increased from 9.8% to 14.7% (p < .01).5 The effect of aging may be expected when considering revascularization,but the same conclusion actually is not as readily deduced for reports of amputations. Because published articles represent a mix of elective and urgent amputations, one cannot compare elective revascularizations to elective amputations. The mortality rates for all urgent/ emergent cases reported in such articles are greater than equivalent elective procedures, an axiom that applies across all areas of general
Figure 1 Typical presenting clinical situation with frank gangrene of the third toe and pregangrenous changes of the two adjoining toes.
and vascular surgery. My review of comparative mortality considered the impact of advanced age (ie, >70 years) and limited the comparison to elective surgeries. Thirty-day operative mortality for either revascularization or amputation in the <70year-old cohort was equivalent (ie, 2.2% versus 1.5%) but was significantly higher for revascularizations (ie, 8%) than for amputations of all types (ie, 1.5%) in patients <70 years (p .5.01).4 When all 465 primary amputations performed in the time interval were considered, a 22% mortality for all urgent amputations made overall mortali-
Figure 2 Photograph demonstrating the extent of dissection and incisions sometimes necessary for an autologous distal bypass procedure.
434 AORN JOURNAL
ty rates similar; this varied from 66% for emergency definitive amputations to 25% for guillotine amputations to 8% for physiologic amputations.6 This clearly illustrates an additional point about comparative mortality, which is that reports of amputations too often carry much higher mortality rates as a function of how pedal sepsis is managed in elderly and/or medically compromised patients. My colleagues and I have reported the lowest published overall mortality rates for major extremity amputation surgery (ie, 2.7% for above-knee, 0.5% for below-knee) in more than 1,OOO consecutive cases; 20% of patients in our series have undergone physiologic amputations with a 5.1%mortality rate.’ The basic rationale for physiologic amputation is that it defers defiiitive surgery to an elective time frame and allows control of the toxic focus as well as correction of all metabolic and hemodynamic abnormalities before surgery.
C0ST:BENEFIT RATIO The increasing importance of economic costs in health care must be considered as one factor in the management decision but ethically should not be a primary or even dominant basis for that decision. Various studies have shown the following. rn Amputation performed without prosthetic fitting (as is usually the case with elderly patients) is less costly than revascularization, but the addition of the prosthesis and rehabilitation costs makes the two procedures equivalent in cost. rn Amputation performed electively and early in a patient’s disease process costs less than amputation performed later in the course of events. The most costly “outliers” in either management regimen are complications from surgery
SEPTEMBER 1995, VOL 62, NO 3
Table 1 INDICATIONS FOR LIMB SALVAGE VERSUS AMPUTATION
Limb salvage Ambulatory patient Limited ambulation, able to transfer Surgically amenable on clinical and anatomic grounds Survival > 1 year expected Reasonableconduit available Limb amputation Nonambulatorv’ .Datient without transfer and/or self-care caDabilitv Limited cognitive ability No reconstructiblevessels lpsilateral paralysis lpsilateral lack of sensation Survival <1 year expected lpsilateral life-threatening or uncontrolled sepsis
and the initiation of complex procedures. The surgeon’s judgment and skill markedly affect the cost to the hospital system.
duit. Although a degree of controversy remains on each of these points, none currently represents any insurmountable impediment to a revascularization attempt.
COMPLICATlNG MEDICAL CONDITIONS Historically, a large number of variables were considered to be relative or absolute contraindications to revascularization. These included age, diabetes, calcified vessels, extensive foot sepsis, extensive midfoot or hindfoot ulcerations, dialysis-dependent renal failure, existing graft infection, poor runoff, and lack of autologous con-
PERIOPERATIVE NURSING ROLE There are a number of specific roles that perioperative nurses play in the evaluation and management of an elderly patient facing the decision to undergo amputation or revascularization.Preoperative nursing evaluation of the psychosocial capabilities of the patient in the context of his or her living situation is an important part of the decision-makingprocess.
NOTES 1. C S O’Mara et al, “Distal bypass for limb salvage in very elderly patients,” The American Surgeon 53 (February 1987) 66-70. 2. LA Scher et al, “Limb salvage in octogenarians and nonagenarians,” Surgery 99 (February 1986) 160-
165. 3. F R Plecha et al, “The early results of vascular surgery in patients 75 years of age and older: An analysis of 3,259 cases,” Journal of Vascular Surgery 2 (November 1985)769-774.
Can the patient currently ambulate? If not, is loss of ambulation likely to be permanent, or is it caused by correctable, severe pain or disability? Does the capability exist for transfer (eg, from bed to wheelchair to shower)? This is especially pertinent in the case of a patient who has undergone previous amputations or an individual with hemiparesis, in which salvage of the remaining functional l&b may be criticifor continued self-care. Is the patient aware of prosthetic possibhies? Is he or she sufficiently motivated to function with a prosthesis? Will the patient likely return to a home environment, or is hospitalizatiodsurgery likely to result in extended convalescence?
CONCLUSION Data and statistics can be (and usually are) manipulated and interpreted to support the purveyor’s wishes. Vascular surgeons generally are committed to the concept of tissue salvage (eg, cerebral, visceral, limb) and are most likely to consider revascularization as the preferable option. It is clear, however, that surgical judgment and basic compassion and empathy for the patient must contribute equally to the decision so that limb salvage should not be performed at all costs, but with reasonable appreciation of the risks, benefits, and costs. A
4. R G Stoney, “Ultimate salvage for the patient with limb-threatening ischemia: Realistic goals and surgical considerations,” American Journal of Surgery 136 (August 1978) 228-232. 5. T J Bunt, J M Malone, “Amputation or revascularization in the >70 year old,” The American Surgeon 60 (May 1994) 349-352. 6. Ibid, 350. 7. T J Bunt et al, “Lower extremity amputation for peripheral vascular disease: A low-risk operation,” The American Surgeon 50 (November 1984) 581-584.
435 AORN JOURNAL
Revascularization versus amputation for elderly patients
P
eripheral and coronary vascular diseases are common in the West; both become clinically important in the latter decades of life, and both are different clinical manifestations of atherosclerosis. The effects of coronary atherosclerosis usually are felt first, with significant mortality due to myocardial infarctions, disabling angina, or ischemic cardiomyopathy. The elderly patient presenting with peripheral vascular disease tends to have a limb salvage situation and significant coexisting illness. The concept of revasculaxization versus primary amputation is a microcosm of the dilemma medicine faces in the nineties. Today’s geriatric patients require costly and time-consuming care and management of their medical problems, but health care providers are under increasing pressure from administrators to minimize patients’ hospital care and costs. Decisions about revascularization or primary amputations in elderly patients can be analyzed carefully on medical and economic grounds, and the decisions need to be individualized. Surgeons depend on perioperative nurses’ complete assessments of patients’ psychosocial statuses as the initial and major determinants of which surgical management option to undertake. Surgeons also depend on perioperative nurses to maximize patients’ ambulatory capacities postoperatively and prevent complications. This is a team approach to patient care.
MEDICAL CONSIDERATIONS Several arguments can be made for primary revascularization or for primary amputation. Revascuhnzafion. Proponents of revascularization base their position on the basic concept of limb preservation because of the attendant benefits of ambulatory ability, sensate protectiveness, and lack of increase in postoperative ambulatory energy expenditure. Limb salvage rates with revascularization actually exceed graft patency rates by 15% to 20%, indicating that limbs may continue to be functional without grafts after the presenting clinical problems (eg, ulcer, gangrenous toes) have resolved (Figure l).’ Five-year patient mortality is high (ie, 35% to 50%)in true limb salvage situations, but the majority of patients (ie, 70% to 80%) can expect to be ambulatory on their salvaged limbs until death.’ Proponents acknowledge the increased mortality of revascularizations in the elderly but note the same mortality rate increase for major amputations as well. They challenge the concept that failed revascularizations lead to higher anatomic levels of amputation than clinically expected and note that increased familiarity and experience with complex distal bypasses (Figure 2 ) has allowed limb salvage attempts in all but a T J BUNT, MD, FACS, is professor of surgery, division of vascular surgery, Lorna Linda (Califl University Medical Center. 433 AORN JOURNAL
small number of patients. Amputation. Proponents of primary amputation base their arguments on the concept of shortened hospital stays, which may translate to lower costs. The proponents also call attention to the increased morbidity and mortality associated with amputations performed for failed revasculari~ations.~ Some institutions have demonstrated equivalent or decreased mortality rates for primary amputations in the elderly. Finally, proponents cite high rates of postoperative prosthetic ambulatory capacity and suggest that early rehabilitation frequently is obtained! It should be noted that such studies have emanated from highly specialized academic centers, are not necessarily applicable to health care in the community, and cannot be readily extrapolated to elderly patients, who less commonly rehabilitate to prostheses. BASIC CONSIDERATIONS Whichever management route is chosen, the medical histories of patients in limb salvage situations (eg, gangrene, ischemic ulcer, rest pain) always must be considered in the decision-making process. The possibility of limb salvage is decreased with increasingly distal and/or repeat attempts at revascularization, and expected long-term survival is decreased in patients with diabetes and those in nursing homes. Thus, the decision for limb amputation or preservation must be made within the confines of limited patient survival and,
SEPTEMBER 1995, VOL 62, NO 3
therefore, may be considered as palliation of the quality of remaining life. Table 1 outlines the basic considerationsthat must be included in an algorithm for patient management.
COMPARATIVE MORBIDITY AND MORTALITY Advanced patient age generally is recognized as an increased risk for all categories of peripheral vascular surgery. This has been borne out by numerous studies and is best exemplified by the extensive Cleveland MetropolitanVascular Registry, in which overall mortality for femoropopliteal/distalrevascularization increased from 2.2% for patients <75 years of age to 6.7% for patients >75 of age, and amputation mortality increased from 9.8% to 14.7% (p < .01).5 The effect of aging may be expected when considering revascularization,but the same conclusion actually is not as readily deduced for reports of amputations. Because published articles represent a mix of elective and urgent amputations, one cannot compare elective revascularizations to elective amputations. The mortality rates for all urgent/ emergent cases reported in such articles are greater than equivalent elective procedures, an axiom that applies across all areas of general
Figure 1 Typical presenting clinical situation with frank gangrene of the third toe and pregangrenous changes of the two adjoining toes.
and vascular surgery. My review of comparative mortality considered the impact of advanced age (ie, >70 years) and limited the comparison to elective surgeries. Thirty-day operative mortality for either revascularization or amputation in the <70year-old cohort was equivalent (ie, 2.2% versus 1.5%) but was significantly higher for revascularizations (ie, 8%) than for amputations of all types (ie, 1.5%) in patients <70 years (p .5.01).4 When all 465 primary amputations performed in the time interval were considered, a 22% mortality for all urgent amputations made overall mortali-
Figure 2 Photograph demonstrating the extent of dissection and incisions sometimes necessary for an autologous distal bypass procedure.
434 AORN JOURNAL
ty rates similar; this varied from 66% for emergency definitive amputations to 25% for guillotine amputations to 8% for physiologic amputations.6 This clearly illustrates an additional point about comparative mortality, which is that reports of amputations too often carry much higher mortality rates as a function of how pedal sepsis is managed in elderly and/or medically compromised patients. My colleagues and I have reported the lowest published overall mortality rates for major extremity amputation surgery (ie, 2.7% for above-knee, 0.5% for below-knee) in more than 1,OOO consecutive cases; 20% of patients in our series have undergone physiologic amputations with a 5.1%mortality rate.’ The basic rationale for physiologic amputation is that it defers defiiitive surgery to an elective time frame and allows control of the toxic focus as well as correction of all metabolic and hemodynamic abnormalities before surgery.
C0ST:BENEFIT RATIO The increasing importance of economic costs in health care must be considered as one factor in the management decision but ethically should not be a primary or even dominant basis for that decision. Various studies have shown the following. rn Amputation performed without prosthetic fitting (as is usually the case with elderly patients) is less costly than revascularization, but the addition of the prosthesis and rehabilitation costs makes the two procedures equivalent in cost. rn Amputation performed electively and early in a patient’s disease process costs less than amputation performed later in the course of events. The most costly “outliers” in either management regimen are complications from surgery
SEPTEMBER 1995, VOL 62, NO 3
Table 1 INDICATIONS FOR LIMB SALVAGE VERSUS AMPUTATION
Limb salvage Ambulatory patient Limited ambulation, able to transfer Surgically amenable on clinical and anatomic grounds Survival > 1 year expected Reasonableconduit available Limb amputation Nonambulatorv’ .Datient without transfer and/or self-care caDabilitv Limited cognitive ability No reconstructiblevessels lpsilateral paralysis lpsilateral lack of sensation Survival <1 year expected lpsilateral life-threatening or uncontrolled sepsis
and the initiation of complex procedures. The surgeon’s judgment and skill markedly affect the cost to the hospital system.
duit. Although a degree of controversy remains on each of these points, none currently represents any insurmountable impediment to a revascularization attempt.
COMPLICATlNG MEDICAL CONDITIONS Historically, a large number of variables were considered to be relative or absolute contraindications to revascularization. These included age, diabetes, calcified vessels, extensive foot sepsis, extensive midfoot or hindfoot ulcerations, dialysis-dependent renal failure, existing graft infection, poor runoff, and lack of autologous con-
PERIOPERATIVE NURSING ROLE There are a number of specific roles that perioperative nurses play in the evaluation and management of an elderly patient facing the decision to undergo amputation or revascularization.Preoperative nursing evaluation of the psychosocial capabilities of the patient in the context of his or her living situation is an important part of the decision-makingprocess.
NOTES 1. C S O’Mara et al, “Distal bypass for limb salvage in very elderly patients,” The American Surgeon 53 (February 1987) 66-70. 2. LA Scher et al, “Limb salvage in octogenarians and nonagenarians,” Surgery 99 (February 1986) 160-
165. 3. F R Plecha et al, “The early results of vascular surgery in patients 75 years of age and older: An analysis of 3,259 cases,” Journal of Vascular Surgery 2 (November 1985)769-774.
Can the patient currently ambulate? If not, is loss of ambulation likely to be permanent, or is it caused by correctable, severe pain or disability? Does the capability exist for transfer (eg, from bed to wheelchair to shower)? This is especially pertinent in the case of a patient who has undergone previous amputations or an individual with hemiparesis, in which salvage of the remaining functional l&b may be criticifor continued self-care. Is the patient aware of prosthetic possibhies? Is he or she sufficiently motivated to function with a prosthesis? Will the patient likely return to a home environment, or is hospitalizatiodsurgery likely to result in extended convalescence?
CONCLUSION Data and statistics can be (and usually are) manipulated and interpreted to support the purveyor’s wishes. Vascular surgeons generally are committed to the concept of tissue salvage (eg, cerebral, visceral, limb) and are most likely to consider revascularization as the preferable option. It is clear, however, that surgical judgment and basic compassion and empathy for the patient must contribute equally to the decision so that limb salvage should not be performed at all costs, but with reasonable appreciation of the risks, benefits, and costs. A
4. R G Stoney, “Ultimate salvage for the patient with limb-threatening ischemia: Realistic goals and surgical considerations,” American Journal of Surgery 136 (August 1978) 228-232. 5. T J Bunt, J M Malone, “Amputation or revascularization in the >70 year old,” The American Surgeon 60 (May 1994) 349-352. 6. Ibid, 350. 7. T J Bunt et al, “Lower extremity amputation for peripheral vascular disease: A low-risk operation,” The American Surgeon 50 (November 1984) 581-584.
435 AORN JOURNAL