Sibiul Medical nr 4_2007.p65

Table 3. Postoperative risk factors
VARIABLE CRUDE DISTRIBUTION
Cases Controls
Heart failure after operation
No 58 64
Yes 7 1
Reoperation
No 60 64
≥ 5 1
Postoperative heparine
No 40 40
≥ 15.000 units days 1 – 3 15 17
≥ 15.000 units days 4 – 10 8
Postoperative Fraxiparine,
Innohep, Fragmin
No 20 20
Yes (TT > 20s) 18 20
Yes (TT ≤20 s) 2 1
Postoperative heart failure was associated with a more
than threefold increase in the risk of amputation. Reoperation
also entailed an increased amputation risk. Postoperative
heparin treatment reduced the risk, but this protective effect
was evident only when heparin was administrated for more
than 3 days. The risk of limb loss after postoperative L.M.H.
(low molecular heparin) treatment was substantially
decreased, by 70 / 80 percent irrespective of whether the
assumed therapeutic level was reached or not.
DISCUSSION:
Thrombosis probably carries a worse prognosiv for
the extremity (1.). While embolism, according to some
autors, entails a heigher risk of early death (2/6). It is
clinically difficult to distingwish between embolism and
trombosis, and a valid discrimination could not be
accomplished in this retrospective review. Some limitations
of this study need consideration. Firstly the matching criteria
applied for section of controls might impose in this group
an over–representation of determinations that increase the
likeluhood of survival for at least 30 days. The most
interesting finding in this study is the protective effect of
postoperative anticoagulation. L.M.H. treatment appears to
be particularly protective, although the small numbers of
exposed individuals give the risk estimates low precision.
Residual confounding might however have contributed
to this protective effect, as patients with arterial fibrilation
and embolism are more likelly to have received oral
anticoagulation than those with arterial hrombosis or oclusion
of uncertain origin. Conflicting reports on this tissue have
appeared for more than 10 years (7, 8, 9, 10, 11, 12). In one
randomized Swedish study, anticoagulation applared to have
no beneficial effect on amputation or mortality rates durring
the first month after operation (13). The strangest risk factor
for amputation was postoperative heart failure. Several
investigations have reported that in some instances the acute
arterial oclusion represents the fisrt sign decreasing flow is
the precipitating factor for arterial thrombosis (1, 12, 13).
Our risk estimates found a 3 – 8 times hogher amputation
risk in patients with heart failure diagnosed as Nyha functional
class 3 or 4 than in patients with functional class 1 or 2. With
the present data, on the other band, multivariate analysis
revealed the risk estimats for postoperative heart failure to
be confounded be the variable former myocardial infarction.
Acute arterial oclusion in connection with myocardial
infarction is often coused by embolism from on endocardial
thrombosis (12, 14). The risk of recurrent embolism is
diminished by anticoagulation treatment. The risk of death,
however, is considerable (12). In patients with atrial
bribrilation, embolism from the left atrium accounts for 80
percent of all acute arterial oclusions (15). The peripheral
arteries in these cases rarely show signs of chronic arterial
insufficiency, and simple embolectomy yields satisfactory.
Results in many instances. In chronic arterial insufficiency
the acute oclusion in the final step in a progressive disease
process and there patients often will not benefit from a simple
Fogarty manoevre(16). The increased risk in the present series
indicates that embolectomy was tried in patients with severe
long – standing and irreversible ischaemia. Where primary
amputation might be a bether alternative. Distal oclusion was
also associated with an increased amputation risk.
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