Walking ability and quality of life as outcome measures in a comparison of arterial reconstruction and leg amputation for the treatment of vascular disease.

OBJECTIVES: To compare the walking ability and the quality of life of patients with severe limb ischaemia treated with an arterial reconstruction (AR) or a primary below-knee amputation (BKA). DESIGN: A cohort study of patients with the first episode of ischaemia. SETTING: University tertiary referral centre. PATIENTS: Thirty-eight (AR 22, BKA 16) patients were studied over a 12-month period with a complete follow-up. CHIEF OUTCOME MEASURES: Walking ability was assessed with a subjective scale and quality of life was measured with the Spitzer QL-INDEX. The results were assessed for patients still alive (Step 1) as well as for all patients (Step 2). RESULTS: Walking ability was better in the AR group at 3 (OR = 10.37; CI 2.12; 50.74; p = 0.004), 6 (OR = 6.47; CI 1.83, 22.79; p = 0.004), and 12 (OR = 3.82; CI 1.20, 12.15; p = (0.03) months. Quality of life was significantly better for AR patients at 3 (OR = 4.32; CI 1.55, 12.02; p = 0.005) and 6 (OR = 4.40; CI 1.68, 11.53; p = (0.003) months, but not at 12 months (OR = 2.44; CI 0.95, 6.26; p = 0.06). the 12 month foot salvage rate was 68%. CONCLUSION: Walking ability and quality of life are better for AR patients than for BKA patients, even with a moderate food salvage rate.

Outcome and quality of life of patients with severe chronic limb ischaemia: a cohort study on the influence of diabetes.

OBJECTIVE: To determine the influence of diabetes on the use of arterial reconstruction, the rate of amputation and death, and the quality of life of patients with severe limb ischaemia. DESIGN: A prospective study of patients with the first episode of ischaemia. SETTING: University tertiary referral centre. METHODS: Thirty-seven patients with diabetes and 50 without diabetes, were studied over a 12 month period with complete follow-up. MAIN OUTCOME MEASURES: The proportion of patients undergoing an arterial reconstruction, amputation rate, death rate, and quality-of-life scores. RESULTS: Patients with diabetes underwent an arterial reconstruction less often than patients without diabetes (7/37 vs. 18/50). The odds of patients with diabetes having a higher incidence of adverse outcome was 1666:1 for minor amputation, 26:1 for major amputation, and 4.7:1 for death. There was a tendency towards a lower quality of life for patients with diabetes at 3 (OR 1.94, p = 0.036), 6 (OR 1.58, p = 0.117), and 12 (OR 1.47, p = 0.185) months. CONCLUSIONS: In patients with diabetes, (1) the opportunity of undergoing an arterial reconstruction is lower, (2) morbidity and mortality are higher, and (3) the quality of life tends to be worse.

[Surgical treatment of infections involving arterial prosthesis in aorto-femoral position]. / Tratamento cirúrgico de infecções comprometendo próteses arteriais em posição aorto-femoral.

This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.

[Infection involving arterial prosthesis: clinical picture, etiology, and predisposing factors]. / Infecção comprometendo próteses arteriais: quadro clínico, etiologia e fatores predisponentes.

Thirty patients were operated for arterial reconstruction with synthetic grafts. They presented one of the following complications: 1) prosthesis exposed by a cutaneous fistula; 2) prosthesis in communication with a hollow viscus; 3) prosthesis involved by pus; 4) positive culture of a fragment of the prosthesis or of the surrounding secretion. The clinical manifestations were cutaneous fistula in 21 patients (70%), external bleeding in 14 (47%), exposition of the prosthesis in five (17%), anastomotic aneurysm in five (17%), and enteric fistula in four (13%). The infection became evident during the first postoperative year in half of the patients. The most important agents of infection were staphyilococci and Gram negative bacteria.

Assessment of quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease.

The purpose of this cohort study was to assess the quality of life of patients with severe ischemia as a result of infrainguinal arterial occlusive disease. Spitzer's QL-INDEX was selected to measure quality of life at baseline and at 3, 6, and 12 months. On the basis of initial treatment, 61 patients were grouped as follows: IC (conservative, n = 31), IR (arterial reconstruction, n = 14), and IA (major amputation, n = 16). After 12 months of follow-up, 48 patients were similarly regrouped according to ultimate treatment as follows: UC (n = 19), UR (n = 9), and UA (n = 20). At 12 months the mean score was significantly higher than the baseline in IC (6.43 vs 3.84, p less than 0.0001) as well as IR (5.64 vs 3.57, p less than 0.01), but not in IA (4.43 vs 3.62). The QL-INDEX mean score was lower in UA than in UC (4.15 vs 6.58, p less than 0.01) or UR (4.15 vs 7.11, p less than 0.0001). The correlation between QL-INDEX and an arbitrary scale was also high (r = 0.726, p less than 0.001). In conclusion, quality of life of patients with limb ischemia can be confidently assessed, improves during the first year of follow-up if major amputation is avoided, and improves and is sustained by a functioning graft.