Background: Mortality rates following major lower extremity amputations (LEAs) 30 days–365 days postoperative have decreased, but 5-year rates remain high at 40.4%–70%. These data may not reflect recent advances in peripheral arterial disease (PAD) care, and comorbidities of chronic PAD may lead to mortality more frequently than the amputation itself. Mortality rates between diabetic and nondiabetic patients were also analyzed. Methods: The California Office of Statewide Health Planning and Development hospital database was queried for patients admitted January 1, 2007–December 31, 2018. ICD-9-CM codes identified patients with vascular disease and an amputation procedure. Results: There were 26,669 patients. The 30-day, 90-day, 1-year, and 5-year major LEA mortality rates were 4.82%, 8.62%, 12.47%, and 18.11%, respectively. Weighted averages of 30-day, 90-day, 1-year, and 5-year major LEA mortality rates in the literature are 13%, 15.40%, 47.93%, and 60.60%, respectively. Mortality risk associated with vascular disease after amputation (hazard ratio = 22.07) was 11 times greater than risk associated with amputation-specific complications from impaired mobility (hazard ratio = 1.90; P < 0.01). Having diabetes was associated with lower mortality at 30 days, 90 days, and 1 year (P < 0.01) but not at 5 years (P = 0.22). Conclusions: This study suggests that people may be living longer after their major LEA than was previously thought. This study suggests that patients’ PAD may play a bigger role in contributing to their mortality than complications from loss of mobility postamputation. Although having diabetes was associated with lower postamputation mortality, the difference was no longer significant by 5 years.

BACKGROUND:Concomitant carpal injuries with dislocations and fracture-dislocations of the carpometacarpal joints (CMCD/FD) are often hard to see on plain radiographs, making advanced imaging a useful diagnostic adjunct. We aim to: (1) characterize bony injury patterns with CMCD/FD; and (2) determine the frequency that preoperative computed tomography (CT) scans change surgical management. METHODS:A retrospective review was performed of patients who underwent operative fixation of CMCD/FD from 2006 to 2021. X-ray and CT scan diagnoses were reviewed and correlated to intraoperative findings and procedures performed. Statistical analyses were performed to evaluate the frequency in which CT scans changed management and the frequency of new intraoperative diagnoses. RESULTS:Seventy-five patients were identified. All patients had a preoperative x-ray, and 27 patients (36%) additionally had a CT scan. Patients who sustained high-velocity trauma were significantly more likely to obtain a CT scan than patients with low-velocity trauma (P = .019); however, the number of additional diagnoses was not significantly associated with trauma velocity (P = .35). Computed tomography scans significantly increased the number of diagnoses (P < .001) and changed operative management in 58% of cases. Six of the 48 patients (12.5%) that did not receive a CT scan had new intraoperative diagnoses, which changed the procedure for five of these patients. New intraoperative diagnoses were identified significantly more when patients did not have a CT scan (P = .04). CONCLUSIONS:Obtaining a CT scan in CMCD/FD patients changed the patient's diagnosis at a significant rate and changed operative management roughly half of the time. The authors recommend routine CT scans be obtained in patients with CMCD/FD.

PURPOSE:To characterize perceptions of ethics among interventional radiologists to guide the development of an applied, specialty-specific approach to ethics.MATERIALS AND METHODS:A 17-question survey on perceptions of ethics and use of ethics resources was developed and vetted via cognitive interviewing of 15 diverse, representative members of the target population. The survey was distributed via the Society of Interventional Radiology, receiving 685 responses (48% participation and 90% completion rates). Responses were compared between different demographics, and common themes from free text responses were identified via content analysis.RESULTS:Most respondents indicated ethics is important for IR (93%) and more focus on practical approaches to ethical issues is needed (73%). Various ethical issues were perceived to be important for IR, but differentiating palliative from futile care was ranked as the top ethical issue. Trainees had more ethics training (P=0.05) but less confidence in navigating ethical issues (P<0.01). Regardless of career stage, those with ethics training (44%) were more confident in navigating ethical issues (P<0.01). Use of resources such as information sheets for patients and resources for coping with complications were variable and limited by lack of availability or knowledge of such resources in IR.CONCLUSIONS:Interventional radiologists believe ethics is important and face diverse ethical issues, but they are challenged by variable experiences and access to practical tools to navigate these challenges.

Objective. To compare the cost-effectiveness of tunneled peritoneal catheter (TPC) versus repeated large-volume paracentesis (LW) for patients with recurrent ascites secondary to gynecological malignancy. Methods. A retrospective cohort study was performed at a single institution from 2016 through 2019 of patients with recurrent ascites from gynecologic malignancies that underwent either TPC or LVP. Data on procedural complications and hospital admissions were extracted. A cost-effectiveness analysis with Markov modeling was performed comparing TPC and LVP. Statistical analyses include base case calculation, Monte Carlo simulations and deterministic sensitivity analyses. Results. There were no significant differences between the cohorts in the average number of hospital days (p = 021) or emergency department visits (p = 0.69) related to ascites. Palliative care was more often involved in the care of patients who had a TPC. The base case calculation showed TPC to be the more cost-effective strategy with a slightly lower health benefit (0.22980 versus 022982 QALY) and lower cost ($3043 versus $3868) relative to LVP (ICER of LVP compared to TPC: $44,863,103/QALY). Probabilistic sensitivity analysis showed TPC was the more cost-effective strategy in 8028/10,000 simulations. Deterministic sensitivity analysis showed TPC to be more cost-effective if its complication risk was >0.81% per 22 days or its procedural cost of TPC insertion was >$1997. When varying the cost of complications, TPC was more cost-effective if the cost of its complication was less than $49,202. Conclusions. TPC is the more cost-effective strategy when compared to LVP in patients with recurrent ascites from gynecological malignancy. (C) 2022 Elsevier Inc. All rights reserved.

Neubauer, Daniel C. MD; Beeson, Summer C. BS; Calvo, Richard PhD; Sise, Michael MD; Martin, Matthew J. MD, FACS; Reid, Christopher MD Author Information

High mortality has been historically associated with below- and above-the-knee amputations (BKA and AKA) performed for chronic limb-threatening ischemia (CLTI). Although 30-day mortality rates have declined, the reported 5-year mortality rates have remained as high as 83%. We investigated the 5-year mortality after BKA and AKA in a modern cohort using a statewide registry. The California Office of Statewide Planning and Development hospital database was queried for patients who had undergone BKA or AKA secondary to CLTI between 2007 and 2018. The cases were selected using the International Classification of Diseases, 9th revision, Clinical Modification diagnosis and procedure codes. Patients who had required amputation after traumatic injury and those with diabetes but without known arterial disease were excluded. Hospital readmission and mortality for a 5-year period after amputation were the outcomes of interest. A total of 26,669 were patients identified: 67% had undergone BKA and 33%, AKA. The average age at surgery was 67 years for the BKA group and 74 years for the AKA group. The most common complications during the initial admission were heart failure (23.88%), dysrhythmia (20.35%), and sepsis (7.81%). The 5-year hospital readmission rate was 71%. The 30-day, 90- day, 1-year, and 5-year mortality rates were 4.82%, 8.62%, 12.47%, and 18%, respectively (Fig). Women had statistically significant higher mortality compared with men (P = .037) across all time periods. When stratified by amputation site, the 5-year mortality was 16% for BKA and 23% for AKA. The mortality difference between AKA and BKA was robust to adjustment for age and comorbidities. Mortality risk associated with vascular disease after amputation was 11 times greater than the risk associated with amputation-specific complications. These results challenge the traditionally ascribed high mid-term mortality rate for patients undergoing amputation for complications of CLTI, with an observed 5-year mortality rate of 18%. Mortality remains higher after AKA than after BKA, likely resulting from the more advanced vascular disease and older age at amputation. Further study is warranted to elucidate whether this observed mortality reduction is from previous rates being exaggerated or advances in patient care.

Peripheral Vascular Disease and Lower Extremity Amputations: Still a Death Sentence? Statewide Analysis with LongTerm Follow-Up Data Daniel C Neubauer, MD, Summer C Beeson, BS, Richard Calvo, PhD, Michael Sise, MD, Matthew J Martin, MD, FACS, Christopher Reid, MD University of California San Diego, San Diego, CA Naval Medical Center San Diego, San Diego, CA University of California San Diego, Coronado, CA Scripps Mercy Hospital, San Diego, CA