Quality of life and not health status improves after major amputation in the elderly critical limb ischemia patient

Objectives A patient-oriented appraisal of treatment has become extremely important, particularly in elderly patients with critical limb ischaemia (CLI). Quality of life (QoL) is an important patient-reported outcome in vascular surgery. Frequently, the physical domain of QoL questionnaires represents an ‘objective’ evaluation of performing activities, which is expected to be impaired after major limb amputation. However, an objective appraisal of physical function is an assessment of health status (HS) and not of QoL. Little is known about the subjective appraisal of physical health (QoL). The goal of this study was to evaluate, prospectively, QoL in relation to HS in elderly CLI patients undergoing major limb amputation. Methods Patients suffering from CLI aged 70 years or older were included in a prospective observational cohort study with a follow-up period of 1 year. Patients were divided according to having had an amputation or not. The World Health Organization Quality Of Life-BREF (WHOQOL-BREF) was used to asses QoL. The 12-Item Short Form Health Survey (SF-12) was used to measure HS. These self-reported questionnaires were completed five times during follow-up.ResultsTwo-hundred patients were included of whom 46 underwent a major limb amputation within one year. Amputees had a statistically significant improvement of their physical QoL after six months (14.0 vs. 9.0 (95% CI -7.84;-1.45),p = 0.005) and after a one-year follow-up (14.0 vs. 9.0 (95% CI -9.58;-1.46),p = 0.008). They did not however show any statistically significant difference in HS. For non-amputees, both physical QoL and HS improved. An instant statistically significant improvement of the physical QoL appeared 1 week after inclusion (12.0 vs. 10.9 (95% CI -1.57;-0.63),p<0.001). Similarly, statistically significant improvement in the physical HS first occurred at 1 week follow-up (29.0 vs. 28.9 (95% CI -5.78; −2.23),p = 0.003). Conclusions There is a clear difference between patients' functioning (HS) and the patients' appraisal of functioning (QoL). In elderly CLI patients, this study clearly suggests a discrepancy between the physical QoL (WHOQOL-BREF) and HS (SF-12) measurements in vascular amputees. This raises the question, which outcome measurement is the most relevant for elderly CLI patients. Individual treatment goals should be kept in mind when assessing the HS or QoL outcome of patients undergoing hospital care. With respect to shared decision making, distinctive and subjective QoL questionnaires, like the WHOQOL-BREF, provide a very important outcome measurement and should be used in future research

Two-year outcome of quality of life and health status for the elderly with chronic limb-threatening ischemia

Purpose:  In elderly patients with chronic limb-threatening ischemia (CLTI), there is little scientific understanding of the long-term changes of quality of life (QoL) and health status (HS) after treatment. The primary goal of this study was to provide long-term QoL and HS results for elderly CLTI patients after therapy. Treatments consisted of endovascular revascularization, surgical revascularization, or conservative treatment. Furthermore, the aim of this study was to identify the distinctive trajectories of QoL and HS. Patients and Methods:  CLTI patients aged >= 70 years were included in a prospective observational cohort study with a two-year follow-up. The WHOQOL-BREF was used to asses QoL. The 12-Item Short Form Health Survey was used to measure HS. The QoL and HS scores were compared to the scores in the general elderly Dutch population. Latent class trajectory analysis was used. Results:  A total of 195 patients were included in this study. After two years, in all treatment groups patients showed significantly higher physical QoL score compared to baseline and there was no significant difference with the corresponding values in the elderly Dutch population. In the latent class trajectory analysis, there were no overlapping risk factors for poorer QoL or HS. Conclusion:  This study shows that QoL levels in surviving elderly CLTI patients in the long-term do not differ from the corresponding values for elderly in the general population. There were no disparities in sociodemographic, clinical and treatment characteristics associated with poorer QoL and HS. This study was carried out to encourage further analysis of the influence of biopsycho social characteristics on QoL and HS in elderly CLTI patients

Prospective Randomized Controlled Trial to Analyze the Effects of Intermittent Pneumatic Compression on Edema Following Autologous Femoropopliteal Bypass Surgery

Background: Patients who undergo autologous femoropopliteal bypass surgery develop postoperative edema in the revascularized leg. The effects of intermittent pneumatic compression (IPC) to treat and to prevent postreconstructive edema were examined in this study. Methods: In a prospective randomized trial, patients were assigned to one of two groups. All patients suffered from peripheral arterial disease, and all were subjected to autologous femoropopliteal bypass reconstruction. Patients in group 1 used a compression stocking (CS) above the knee exerting 18 mmHg (class I) on the leg postoperatively for 1 week (day and night). Patients in group 2 used IPC on the foot postoperatively at night for 1 week. The lower leg circumference was measured preoperatively and at five postoperative time points. A multivariate analysis was done using a mixed model analysis of variance. Results: A total of 57 patients were analyzed (CS 28; IPC 29). Indications for operation were severe claudication (CS 13; IPC 13), rest pain (10/5), or tissue loss (7/11). Revascularization was performed with either a supragenicular (CS 13; IPC10) or an infragenicular (CS 15; IPC 19) autologous bypass. Leg circumference increased on day 1 (CS/IPC): 0.4%/2.7%, day 4 (2.1%/6.1%), day 7 (2.5%/7.9%), day 14 (4.7%/7.3%), and day 90 (1.0%/3.3%) from baseline (preoperative situation). On days 1, 4, and 7 there was a significant difference in leg circumference between the two treatment groups. Conclusions: Edema following femoropopliteal bypass surgery occurs in all patients. For the prevention and treatment of that edema the use of a class I CS proved superior to treatment with IPC. The use of CS remains the recommended practice following femoropopliteal bypass surgery

Peri-Operative Nasal Eradication Therapy Prevents Staphylococcus aureus Surgical Site Infections in Aortoiliac Surgery

Background: Surgical site infections (SSIs) cause considerable morbidity and deaths among patients undergoing vascular surgery. Pre-operative screening and subsequent treatment of nasal Staphylococcus aureus carriers with mupirocin and chlorhexidine reduces the risk of SSIs in cardiothoracic and orthopedic surgery. The aim of this study was to investigate the effect of this screen-and-treat strategy on the development of SSI in patients undergoing aortoiliac surgery. Methods: A prospective study was performed that enrolled an intervention cohort comprising all patients undergoing aortoiliac surgery from February 2013 to December 2016. Before surgery, patients were screened for S. aureus nasal carriage and, if positive, were treated with mupirocin nasal ointment and chlorhexidine body washes. The presence of SSI was recorded on the basis of the criteria of the U.S. Centers for Disease Control and Prevention. A historic control group was used, consisting of aortoiliac surgery patients in 2010 who tested positive for S. aureus but received no treatment. Results: A total of 374 patients in the study cohort were screened of whom 75 (20.1%) tested positive for S. aureus. Of these patients, 68 were given eradication therapy. In the 2010 cohort, 22 patients (15.7%) were positive. The incidence of S. aureus infection was 0 of 75 in the treatment group versus 3 of 22 (13.6%) in the control group (p = 0.021). Both the 30-day mortality rate (1.3% vs. 13.6%; p = 0.035) and the rate of re-interventions (12.0% vs. 31.8%) were significantly lower in the treated group. Conclusion: We conclude that S. aureus nasal screening and eradication with mupirocin and chlorhexidine reduces S. aureus SSI and its complications after aortoiliac surgery

Peri-Operative Nasal Eradication Therapy Prevents Staphylococcus aureus Surgical Site Infections in Aortoiliac Surgery

Background: Surgical site infections (SSIs) cause considerable morbidity and deaths among patients undergoing vascular surgery. Pre-operative screening and subsequent treatment of nasal Staphylococcus aureus carriers with mupirocin and chlorhexidine reduces the risk of SSIs in cardiothoracic and orthopedic surgery. The aim of this study was to investigate the effect of this screen-and-treat strategy on the development of SSI in patients undergoing aortoiliac surgery. Methods: A prospective study was performed that enrolled an intervention cohort comprising all patients undergoing aortoiliac surgery from February 2013 to December 2016. Before surgery, patients were screened for S. aureus nasal carriage and, if positive, were treated with mupirocin nasal ointment and chlorhexidine body washes. The presence of SSI was recorded on the basis of the criteria of the U.S. Centers for Disease Control and Prevention. A historic control group was used, consisting of aortoiliac surgery patients in 2010 who tested positive for S. aureus but received no treatment. Results: A total of 374 patients in the study cohort were screened of whom 75 (20.1%) tested positive for S. aureus. Of these patients, 68 were given eradication therapy. In the 2010 cohort, 22 patients (15.7%) were positive. The incidence of S. aureus infection was 0 of 75 in the treatment group versus 3 of 22 (13.6%) in the control group (p = 0.021). Both the 30-day mortality rate (1.3% vs. 13.6%; p = 0.035) and the rate of re-interventions (12.0% vs. 31.8%) were significantly lower in the treated group. Conclusion: We conclude that S. aureus nasal screening and eradication with mupirocin and chlorhexidine reduces S. aureus SSI and its complications after aortoiliac surgery

Is there an important role for anxiety and depression in the elderly patients with critical limb ischemia, especially after major amputation?

Background:  In patients with critical limb ischemia, an association is assumed between depression and worse outcome for morbidity, such as major limb amputation. After major amputation, anxiety and depression are common. We aimed to determine the association of depressive and anxiety symptoms in the elderly with critical limb ischemia, especially after major limb amputation. Methods:  Patients with critical limb ischemia aged >= 70 years were included in this prospective observational cohort study between January 2012 and February 2016 in 2 Dutch hospitals. After a multidisciplinary vascular conference, patients were divided into 4 treatment groups: endovascular revascularization, surgical revascularization, conservative therapy, and primary major amputation. In a 1-year follow-up period, depression and anxiety were measured 4 times using the Dutch versions of the Center for Epidemiological Studies Depression Scale and the State-Trait Anxiety Inventory. Results:  One Hundred eighty-seven patients were included. Within 1 year, 44 patients underwent a major limb amputation. Lower amputation-free survival did not differ significantly for patients with versus without greater anxiety (X-2 [1] = 0.689, P = 0.407) and also not for patients with versus without more depressive symptoms (X-2 [1] = 0.614, P = 0.433). For both groups, there were no significant changes in anxiety scores over time. After a median follow-up time of 336.5 days and 365 days, depressive symptoms significantly decreased in amputees, respectively, 8.5 vs. 4.5 (95% CI 1.76-7.48, P = 0.002) and 8.5 vs. 4.3 (95% CI 0.61-9.82, P = 0.027) when compared to the baseline measurement. Similarly, nonamputees had significantly lower overall score for depressive symptoms after a median follow-up time of 365 days (10.1 vs. 4.1, 95% CI 4.49 to 6.90, P <0.001). Conclusions:  In the opinion of the medical health care provider, amputation is a severe and unwanted end phase of critical limb ischemia. However, depressive symptoms seem to decrease over time and anxiety symptoms do not seem to be affected in patients after major limb amputation. In addition, patients with greater trait anxiety or more depressive symptoms at baseline did not have significantly higher amputation rates. These findings are similar to the course of depressive and anxiety symptoms for the elderly patients without major limb amputation