Etiology and outcomes of amputation in patients with peripheral artery disease in the EUCLID trial.

Autor:	Govsyeyev N; CPC Clinical Research, Aurora, Colo; Division of Vascular Surgery, Department of Surgery, University of Colorado Department of Surgery, Aurora, Colo. Electronic address: nicholas.govsyeyev@cuanschutz.edu., Nehler MR; CPC Clinical Research, Aurora, Colo; Division of Vascular Surgery, Department of Surgery, University of Colorado Department of Surgery, Aurora, Colo., Low Wang CC; Division of Endocrinology, Metabolism, and Diabetes, University of Colorado School of Medicine, Aurora, Colo., Kavanagh S; CPC Clinical Research, Aurora, Colo., Hiatt WR; CPC Clinical Research, Aurora, Colo; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo., Long C; Duke University Medical Center, Durham, NC., Jones WS; Duke University Medical Center, Durham, NC., Fowkes FGR; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland., Berger JS; NYU School of Medicine, New York, NY., Baumgartner I; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland., Patel MR; Duke University Medical Center, Durham, NC., Goodney PP; Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH., Beckman JA; Division of Cardiovascular Medicine, Department of Medicine, Nashville, Tenn., Katona BG; Astra Zeneca, Gaithersburg, Md., Mahaffey KW; Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, Calif., Blomster J; Department of Medicine, University of Turku, Turku, Finland., Norgren L; Department of Surgery, Örebro University, Örebro, Sweden., Bonaca MP; CPC Clinical Research, Aurora, Colo; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colo.
Jazyk:	angličtina
Zdroj:	Journal of vascular surgery [J Vasc Surg] 2022 Feb; Vol. 75 (2), pp. 660-670.e3. Date of Electronic Publication: 2021 Sep 28.
DOI:	10.1016/j.jvs.2021.08.096
Abstrakt:	Objective: Amputation remains a frequent and feared outcome in patients with peripheral artery disease (PAD). Although typically characterized as major or minor on the extent of tissue loss, the etiologies and outcomes after amputation by extent are not well-understood. In addition, emerging data suggest that the drivers and outcomes of amputation in patients with PAD may differ in those with and without diabetes mellitus (DM). Methods: The EUCLID trial randomized 13,885 patients with symptomatic PAD, including 5345 with concomitant diabetes, to ticagrelor or clopidogrel and followed them for long-term outcomes. Amputations were prospectively reported by trial investigators. Their primary and contributing drivers were adjudicated using safety data, including infection, ischemia, or multifactorial etiologies. Outcomes following major and minor amputations were analyzed, including recurrent amputation, major adverse limb events, adverse cardiovascular events, and mortality. Multivariable logistic regression models were used to identify independent predictors of minor amputations. Analyses were performed overall and stratified by the presence or absence of DM at baseline. Results: Of the patients randomized, 398 (2.9%) underwent at least one lower extremity nontraumatic amputation, for a total of 511 amputations (255 major and 256 minor) over a median of 30 months. A history of minor amputation was the strongest independent predictor for a subsequent minor amputation (odds ratio, 7.29; 95% confidence interval, 5.17-10.30; P < .001) followed by comorbid DM (odds ratio, 4.60; 95% confidence interval, 3.16-6.69; P < .001). Compared with patients who had a major amputation, those with a minor amputation had similar rates of subsequent major amputation (12.2% vs 13.6%), major adverse limb events (15.1% vs 14.9%), and major adverse cardiovascular events (17.6% vs 16.3%). Ischemia alone was the primary driver of amputation (51%), followed by infection alone (27%), and multifactorial etiologies (22%); however, infection was the most frequent driver in those with DM (58%) but not in those without DM (15%). Conclusions: Outcomes after amputation remain poor regardless of whether they are categorized as major or minor. The pattern of amputation drivers in PAD differs by history of DM, with infection being the dominant etiology in those with DM and ischemia in those without DM. Greater focus is needed on the prognostic importance of minor amputation and of the multifactorial etiologies of amputation in PAD. Nomenclature with anatomical description of amputations and eliminating terms "major" or "minor" would seem appropriate. (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
Databáze:	MEDLINE
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