Elsevier

Annals of Vascular Surgery

Volume 27, Issue 8, November 2013, Pages 1105-1114
Annals of Vascular Surgery

Clinical Research
Systematic Review on Health-Related Quality of Life After Revascularization and Primary Amputation in Patients With Critical Limb Ischemia

https://doi.org/10.1016/j.avsg.2013.01.010Get rights and content

Background

The purpose of this study was to assess the effect of revascularization (bypass surgery, angioplasty) and primary amputation on health-related quality of life (QoL) in patients with critical limb ischemia (CLI; resting pain or tissue loss).

Methods

A systematic review of the literature was performed through an electronic search of PubMed (from 1985 to 2012) and Embase (from 1985 to 2012) by two independent investigators to identify English-language articles investigating health-related QoL in regard to CLI.

Results

Three observational studies were identified describing a comparison between primary amputation and revascularization and their effects on QoL in patients with CLI, all concluding that revascularization should be attempted. Data pooling was omitted due to the impossibility of combining outcome parameters. A separate analysis of each article is presented.

Conclusions

Patients with CLI have poor health prospects and life expectancy, irrespective of treatment administered. Randomized trials of health-related QoL after revascularization versus primary amputation are nonexistent. Also, the available observational studies do not allow sound conclusions, due to small numbers and methodologic imperfections. Therefore, no recommendations of either therapy in patients with CLI can be made with respect to an anticipated improvement in QoL.

Introduction

The estimated incidence of critical limb ischemia (CLI; pain at rest or tissue loss) in Western countries is approximately 50–100 per 100,000 persons per year, representing a major burden on health- and social-care resources.1 Despite advances in medical therapies and preventive strategies, the number of patients requiring lower limb revascularization for CLI is expected to grow due to the aging of populations, continuing nicotine abuse, and the increasing prevalence of diabetes with its related vascular complications.2, 3

The goals of treatment in patients with critical limb ischemia are to reduce discomfort, increase mobility, and improve community-based functional status, or to preserve or reinstate their premorbid functional status. These goals may be achieved with either limb salvage or primary amputation. In many of these patients, attempts at revascularization will lead to a prolonged hospital stay with multiple operations and associated complications, costs, and loss of quality of life (QoL). Despite the often numerous efforts to salvage the affected limb, many of these patients will ultimately undergo amputation above the ankle level or will fail to become ambulatory despite limb salvage.4 Because CLI is reflective of systemic atherosclerosis, the morbidity and mortality of this disease and its treatment is high.5, 6 Although successful revascularization has been associated with improved QoL in patients with CLI,7, 8 functional outcome is not determined solely by traditional, physician-oriented measures of reconstruction patency and limb salvage, but also by patient comorbidy.9 Realistically, successful revascularization does not warrant full functional capacity.10 Therefore, the question arises whether revascularization indeed improves QoL (i.e., enhances the patient’s ability to enjoy normal activities of life) when compared with major limb amputation in selected patients. To address this issue of prolonged postoperative morbidity without significant benefit, subsets of patients who may be best helped by primary amputation have been determined previously.11

In this study we performed a systematic review of the literature on QoL in patients with CLI treated with primary amputation compared with any other form of revascularization.

Section snippets

Search Strategy

An electronic literature search was performed of PubMed (from 1985 to 2012) and Embase (from 1985 to 2012) by two independent investigators (J.B. and A.C.V.) to identify articles in the English language investigating health-related QoL with regard to CLI. The period 1985–2012 was arbitrarily chosen, because it was considered plausible that the perception of “quality of life” in the 1960s and 1970s was fundamentally different than in more recent years. Search terms were determined describing the

Results

Combining the search terms (Table I) resulted in the identification of 36 articles in PubMed,4, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46 of which 11 were reviews, 1 was in Japanese, and 1 in Slovak, leaving 23 articles. After screening of titles and abstracts, 21 were omitted for different reasons, leaving 2 suitable articles.12, 13 The Embase search using identical terms yielded 2 articles, of

Discussion

Although the observational studies reviewed in this report suggest a QoL benefit from revascularization when compared with primary amputation, there is no sound evidence available to support this opinion. Also, the observed advantage of revascularization in comparison with amputation is probably only temporary. Amputation after revascularization is associated with a catastrophic decline in QoL, and premorbid state heavily influences the postoperative functional outcome. These findings stress

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