Relation between rates of leg amputation and distal arterial reconstructive surgery

BMJ 1994; 309 doi: (Published 03 December 1994) Cite this as: BMJ 1994;309:1479
  1. J A Michaels,
  2. P Rutter,
  3. J Collin,
  4. F M Legg,
  5. R B Galland for the Oxford Regional Vascular Audit Group
  1. Nuffield Department of Surgery, Oxford University, John Radcliffe Hospital, Oxford clinical lecturer, consultant surgeon, reader in surgery, clinical audit assistant, consultant surgeon.
  1. Correspondence to: Mr J A Michaels, Northern General Hospital NHS Trust, Sheffield S5 7AU.
  • Accepted 23 August 1994

A recent audit of vascular surgical practice in the Oxford region showed distinct variation between districts in the rate and level of leg amputations for occlusive arterial disease.1 There were also considerable differences between districts in the volume and nature of reconstructive arterial surgery. Arterial bypass grafting of the calf or foot, operations largely reserved for limb salvage, were undertaken in only two hospitals in the region.

We carried out a six month prospective audit to study in greater detail the relation between distal reconstructive arterial surgery and leg amputation.

Subjects, methods, and results

The Oxford region has a total population of 2.5 million, with eight districts serving populations of 150 000 to 550 000. On the basis of the previous audit we divided districts into three high volume and five low volume districts, depending on whether they were carrying out above or below the average rate of arterial reconstructions for the region.1

Vascular surgeons in each district were invited to participate in a prospective audit of all leg amputations and vascular reconstructions distal to the inguinal ligament over six months. Amputations for trauma or malignancy were excluded. A single datasheet was completed giving details of each procedure carried out, the indication, the patient's district of residence, where the operation was performed, and details of previous investigations or treatment.

Details of reconstructive surgery and amputations carried out in districts with below (low volume) and above (high volume) the average rate of arterial reconstructions in the Oxford region. Values are numbers or proportions (percentages)

View this table:
View this table:

At the end of six months all theatre records in participating districts were checked by one of the participants or an audit assistant. Additional forms were completed from the notes of those patients who had been omitted.

Completed forms for all patients identified by a subsequent check of theatre records were received from five districts, covering a total population of 1.9 million, two of these districts being high volume and three low volume, as defined above. Differences between centres in high and low volume districts were analysed by using a Chi2 test with correction for continuity.

Overall, data were collected for 137 reconstructions and 93 amputations, 79 of which were the first major amputation of that leg. These represent rates of 11.7, 9.6, and 8.2 procedures per 100000 of the population respectively.

In the high volume districts more patients had been referred from outside the district, more reconstructive procedures were preceded by balloon angioplasty, and more reconstructive procedures entailed arterial bypass grafting to the calf or foot and use of autologous vein. These districts had a lower rate of amputation, a higher proportion of below knee amputations, and a higher proportion of patients who had undergone previous angiography or surgical treatment (table).


Access to vascular surgery is variable and depends on district of residence.1 Our findings show that districts with high rates of distal arterial reconstructions do fewer amputations and that amputations are carried out more distally and are more likely to be preceded by investigations or surgical attempts to save the leg.

We conclude that an expansion in specialist vascular surgical services in the Oxford region and more widespread use of distal arterial reconstructive surgery would result in substantial reductions in the number of leg amputations with consequent savings in both disability and cost.2 These findings are supported by studies elsewhere3 and shed further light on the debate about the provision of specialist vascular surgical services.4

This work was presented orally at the annual scientific meeting of the Association of Surgeons of Great Britain and Northern Ireland in Harrogate in April 1994.

We thank all the surgeons in the Oxford region who participated in this study.


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