Risk Factors for Contralateral Limb Loss in Patients with a Prior Major Amputation
Patricia Yau, M.D.1, Katherine Maccallum1, Charles DeCarlo, MD2, John Phair, MD1, Saadat Shariff, MD1, Larry Scher, MD1, Evan Lipsitz, MD1, Karan Garg, MD1.
1Montefiore Medical Center, Bronx, NY, USA, 2Massachusetts General Hospital, Boston, MA, USA.
Introduction and Objectives: Patients with peripheral arterial disease or diabetes who undergo major lower extremity amputation are at risk for subsequent contralateral limb loss. Progression to bilateral major amputation significantly impacts long-term functional status and quality of life. Risk factors for contralateral limb loss in these patients have not been well elucidated. We sought to describe rates and predictors of contralateral major amputation after index major amputation.
Methods: We conducted a retrospective review of all consecutive patients undergoing index major lower extremity amputation for vascular related disease between 2009 and 2014. The outcome of interest was contralateral major amputation. Cox proportional hazards models were used to identify predictors of contralateral major amputation.
Results: There were 689 patients who underwent either an Above-Knee Amputation (AKA, 37.9%) or Below-Knee-Amputation (BKA, 62.1%). Mean age was 69.4+/-14.7 years, 52.8% were male, and 31.2% were non-ambulatory. 72.9% were diabetic, 17.0% had end stage renal disease on dialysis, 57.4% had coronary artery disease, and 44.7% had peripheral arterial disease. During the first post-operative year, 5.5% underwent contralateral major amputation, and 10.2% underwent contralateral major amputation by 5-year follow-up. Patients who underwent a contralateral major amputation within one year had a higher rate of one-year mortality (OR 1.97, 95% CI 1.00-3.86). Cox regression analysis revealed higher level amputation (HR 1.91, 95% CI 1.51-3.19), admission from nursing home (HR 1.69, 95% CI 1.03-2.78), atherosclerosis (defined as history of coronary artery disease or peripheral arterial disease; HR 2.26, 95% CI 1.18-4.32), and ischemic tissue loss (HR 2.02, 95% CI 1.12-3.64) as independent risk factors for contralateral amputation.
Conclusion: Progression to bilateral major amputation within the first post-operative year after index major amputation occurs in a significant number of patients and is associated with increased one-year mortality. AKA, atherosclerosis, and ischemic tissue loss are predictors of subsequent contralateral amputation. These patients may benefit from closer surveillance and aggressive medical and surgical management to prevent progression to bilateral amputation. 
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