People in their 50s with severe peripheral artery disease (PAD) may have a higher chance of needing leg amputation one to five years after emergency surgery to restore blood flow to the lower limbs compared to those in their 80s, according to recent research published in the American Heart Association’s main journal Circulation.
Peripheral artery disease affects 10-12 million adults aged 40 and older in the U.S., leading to narrowed arteries and reduced blood flow, particularly in the lower extremities. This condition causes severe cramping and pain while walking, climbing stairs, or exercising and is linked to modifiable risk factors such as smoking, diabetes, hypertension, and abnormal cholesterol levels.
“People with severe forms of PAD requiring urgent surgery tend to have extremely poor disease progress. They are at high risk of limb loss and all-cause death following the initial surgery,” said study lead author Qiuju Li, Ph.D., a research fellow in medical statistics at the London School of Hygiene and Tropical Medicine in the United Kingdom. “Our primary finding is different from the traditional belief that older people were at an increased risk of major amputation. Our study, interestingly, shows the opposite relationship.”
This comprehensive study examined data from almost 95,000 adults over the age of 50 who underwent revascularization for peripheral artery disease between 2013 and 2020 in England. The study aimed to assess the risk of major limb amputation and mortality following revascularization. Major limb amputation was specifically defined as amputation above the ankle.
Of the participants reviewed, two-thirds underwent revascularization during scheduled hospital admissions, while the remaining individuals had non-elective procedures during emergency hospital admissions.
The data illustrates significant differences in the risk of major amputation and mortality following revascularization procedures based on age and admission type. For emergency admissions, patients aged 50-54 faced a major amputation risk of 18% at one year and 28.8% at five years, while those aged 80-84 had a risk of 11.9% and 17% at one and five years, respectively.
In comparison, elective revascularization resulted in lower amputation risks, with patients aged 50-54 and 80-84 facing 10.8% and 6.5% risks at five years, respectively. However, older patients experienced a substantially higher risk of death without amputation within five years following both elective and emergency revascularizations.
Furthermore, participants, especially those aged 80-84, faced significantly higher 1-year death rates after major amputation if it occurred within six months of revascularization.
“The findings also highlight how the association between the illness trajectories and patient characteristics is not straightforward,” Li said. “While being older at the time they had blood flow-restoring surgery was associated with a marked increase in the risk of death, the risk of major amputation after that surgery was lower among older patients rather than younger patients.”
In May 2024, the American Heart Association, the American College of Cardiology, and nine other medical societies released comprehensive guidelines stressing the critical importance of early diagnosis and treatment in the prevention of amputation and other cardiovascular complications associated with lower extremity peripheral artery disease. The guidelines also underscored the necessity of coordinated care from a multispecialty team to effectively address the condition.
“This study shows that for patients with severe peripheral arterial disease, there is not one simple answer that can explain each patient’s condition,” said guidelines co-vice chair Philip Goodney, M.D., M.S., professor and section chief of Vascular Surgery at Dartmouth Health in New Hampshire. “For example, patients with severe disease who present at young ages have poor outcomes, irrespective of how they might be treated. This may be the result of severe disease or difficult circumstances for treatment.”
“Either way, this information can help guide clinicians and researchers in determining the best treatments for these high-risk individuals. Similarly, the study also shows that older patients with moderate to severe disease can have good results when trying to prevent an amputation. Overall, these findings make it clear – in treatment for PAD, it is not ‘one size fits all.’”
The analysis had a few limitations that might have impacted the results. The data review didn’t consider subsequent surgeries to restore blood flow after the initial surgery, disease severity, or whether amputation occurred on the leg that underwent the initial surgery or the other leg. Additionally, race or ethnicity was not factored in due to unreliable information from the database.
The data review involved 94,690 individuals with peripheral artery disease who underwent surgery to restore blood flow to the lower limbs between April 2013 and March 2020 in England. Participants were aged 50 and older, with a median age of 72 years, and 66% were men. Data was collected from the Hospital Episode Statistics Admitted Patient Care database in England.
A statistical model was developed from the data to depict survival patterns after initial lower limb revascularization, occurrence of major amputation, and survival after amputation. During the follow-up period ending in March 2021, a total of 10.0% of patients underwent major amputation. Two thirds of these cases were emergency patients upon admission, and more than half of them had passed away by the end of the study.
The revascularization procedure was categorized as elective if performed during an elective admission and non-elective if performed during an emergency admission or after transfer from another hospital.