During the past 15 years, the number of major dysvascular amputations (defined as amputations above the ankle) performed annually has decreased. However, major amputation (MA) continues to be a primary therapy and is frequently the only treatment offered for critical limb ischemia (CLI).1,2


The treatment of CLI in the United States has been characterized as a “Pathway to Amputation,” a phrase coined by Allie et al, who found that amputation was the first procedure in 67% of Medicare patients who underwent MA.1 A 2012 study of 20,464 Medicare patients with CLI who underwent MA found strikingly similar results. Seventy-one percent had no revascularization, and 54% had no angiogram obtained before an MA.2

Approximately 65,000 to 70,000 MAs are currently performed for peripheral artery disease (PAD), and almost all of these patients suffer from the end stage of PAD, known as CLI.3,4 Between 25% and 33% of Medicare CLI patients undergo primary amputation.5,6


Numerous studies have demonstrated that the probability of undergoing amputation depends on who you are and where you live: the “Amputation Lottery.”2,5,7-19 Minority race, lower socioeconomic status, age, sex, insurance payer, and low hospital volume have all been shown to increase the probability of MA.5,7-15 Medicare and Medicaid patients are more likely to undergo MA than privately insured patients, with Medicaid patients being the most likely.5,8

Geographic location is associated with different probabilities of amputation and variations in vascular procedures (such as lower extremity surgical bypass, endovascular revascularization, or diagnostic endovascular evaluation) offered to Medicare patients before they are referred for an amputation.2,16-18,20 Similar amputation rates are found in neighboring hospital referral regions (HRRs). Hospitals with high amputation rates are surrounded by neighboring clusters of HRRs that also have high rates of amputation.16 Geographic differences in amputation rates persist even after adjustment for regional differences in age, sex, race, comorbidities, and year of amputation.17 It is hypothesized that these differences reflect variations in the practice of medicine, or “practice heterogeneity,”2,16,20,21 which is partially due to the absence of published expert consensus or guideline documents to provide the definition of a salvageable limb and the diagnostic and therapeutic strategies necessary for adequate management.22,23


Angiography is protective against MA; however, it is underutilized in CLI. A recent study of more than 1 million Medicare inpatients with CLI found that an angiogram reduced the odds of amputation by 90%.5 However, angiography was performed in only 27% of these hospitalized CLI patients.5 Other studies have also found low utilization of angiography before amputation.1,2,24 It has become widely known that performance of selective angiography (defined as an angiogram obtained with a catheter placed as far as the P3 segment of the popliteal artery) reveals the presence of disease that is far less severe than that identified by abdominal angiography with runoff, CT, or MRI. This can also be complemented by retrograde angiography (performed through tibial, pedal, or digital access) or by specialized high-frequency duplex ultrasound imaging. These modalities allow the identification of therapeutic targets in the distal tibial, pedal, and even digital arteries, which have been accessed and treated by a few operators worldwide with an amazing rate of technical and clinical success.25


Compared with other surgical procedures, MA has high perioperative morbidity and mortality, as well as high revision rates. Above-knee amputation (AKA) and below-knee amputation (BKA) are among the top five surgical procedures with the highest perioperative mortality.26 Five percent to 10% of BKA patients and 15% to 20% of AKA patients die in the hospital before discharge.27-30 Rates of perioperative mortality for infrainguinal bypass and endovascular revascularization are 2% to 8% and 1% to 3%, respectively.31-36

The 20% to 37% major complication rate associated with amputation is considerably higher than the 16% to 17% average for vascular surgery and the average of 5% to 9% for endovascular surgery.26,33,34,37-39 Wound infection, the most frequent complication, occurs at a rate of 10% to 30% and, if not resolved, can lead to reamputation at a higher level.27,28,40,41 In-hospital amputation revision rates are 13% to 20% for BKA and 8% to 12% for AKA procedures.42,43 Other serious complications include high rates of deep vein thrombosis (13%–26%), cardiac complications (9%–10%), sepsis (9%), bleeding (8%), and renal failure (2%–3%).28,29,44-47


What are the economic costs of amputation? MA is costly, ranking as the sixth most expensive surgical procedure performed in the United States.48 The macroeconomic cost of amputation is estimated at $10.6 billion.49 Medicare and Medicaid pay the majority, or almost 80% of the national bill (Figure 1).50

Inpatient hospital costs are the largest single component, representing about 45% of total annual amputation costs (Figure 2). Outpatient and physician follow-up costs account for about 20% and nursing home costs, for 12% to 16%. The rest of costs are related to rehabilitation, home health care, and durable medical equipment.42


Does primary amputation represent the best allocation of scarce health care resources? How do the costs and the outcomes of amputation compare with the alternative therapies for CLI: bypass surgery and endovascular revascularization?

In order to answer these questions, it is necessary to focus on costs rather than charges and to employ only United States cost studies, as costs in other countries can vary considerably due to differences in the organization of the health care system, prices, and reimbursement systems.51 Charges represent the dollar amount billed to the patient or the payer and show a poor correlation with the actual cost of care as measured by the resources consumed.52

The 2012 study by Barshes et al, which compares primary amputation with revascularization, is the only cost-effectiveness analysis of CLI therapies published in the last 15 years. This analysis was conducted from a broad socioeconomic point of view and included all inpatient and outpatient costs, except for the impact of lost wages. Amputation was found to be less cost-effective than either surgical bypass or endovascular revascularization.53 A 1999 analysis comparing amputation to surgical bypass also concluded that amputation was less cost-effective than bypass.54

Data from the US PAD cohort of the Reduction of Atherothrombosis for Continued Health (REACH) registry provide insight into cardiovascular costs, a significant component of the total bill associated with amputation and revascularization. At 2 years, mean annual hospitalization and medication costs in 2004 dollars for those who had undergone previous amputation ($11,963) exceeded costs of those who had undergone previous revascularization ($10,430).55

Because Medicare and Medicaid (which are funded by US tax payers) pay for the majority of amputations, it is informative to examine the impact of the “Pathway to Amputation” on hospital costs. Unfortunately, no recent United States studies have done this. In the late 1980s, a number of single-center, nonrandomized studies compared surgical bypass with amputation.56-58 These studies examined charges (reimbursements), rather than costs. In general, charges were similar for uncomplicated amputation and bypass. Complications and repeat procedures increased charges significantly for both procedures. However, when charges generated by higher rates of complications and revisions were taken into account, amputation was more expensive than bypass.56-59

Examination of the Healthcare Cost and Utilization Project (HCUP) data shows that average procedure costs for amputation and endovascular revascularization are similar.60,61 However, costs associated with in-hospital mortality, morbidity, and repeat procedures increase total costs and need to be included for an accurate assessment of the financial burden.62,63

Lacking CLI-specific data, costs of in-hospital morbidity and mortality reported in the vascular and general surgical literature have been inflated to 2010 dollars. The average cost of an in-hospital death exceeds $18,000.64 Each type of complication generates additional costs. For example, the average hospital cost of a wound infection is $19,000 to $42,000, a deep vein thrombosis costs over $14,000, and so on for each complication.65 The cost of a revision procedure after a failed or complicated surgical procedure can conservatively be assumed to be at least as much as the original. When costs of mortality, morbidity, and revisions are calculated and added to the initial procedure cost, the total cost of primary amputation exceeds that of an endovascular revascularization by almost $10,000.49


Amputees are heavy users of hospital resources in the first month after the amputation, experiencing frequent readmissions.42,66 They are readmitted for amputation as well as for nonamputation reasons.42,66 Thirty-day all-cause readmissions for Medicare patients who undergo amputation exceed those of the average Medicare patient (26% vs 20%).67,68 In one study, about half of the readmissions were amputation-related, whereas 21% were due to cardiovascular or cerebrovascular disease.66

In the subsequent year or years, amputees continue to require frequent hospitalizations, with hospital utilization surpassing that of other chronic disease patients.42,66 During a mean follow-up of 3.25 years, Henry and colleagues found high rates of readmissions and lengthy stays. Amputees were readmitted 19.5 times per person-year, with a length of stay of 71.2 days per person-year.66 Length of stay exceeded that for CLI patients after revascularization with surgical bypass and far exceeded that of patients undergoing treatment for metastatic lung cancer and recurrent or refractory ovarian cancer.66

It can be concluded that in CLI patients, amputation is not the final treatment. Instead, the initial amputation is followed by revisions, more proximal amputations, contralateral amputations, and cardiovascular procedures.66 All of these add to the total economic burden.


Even at almost $11 billion, the costs of amputation are understated because this estimate does not include direct patient costs and societal costs of lost productivity. Societal costs can be assessed by including lost production days (of patients and their family member caregivers), the increase in the number of disabled citizens, and the overall negative impact on society and the economy.

The inability to work, on the part of the patient and/ or caregiver, results in lost wages, reduces productivity, and negatively affects economic growth. Long-term care research has shown that caregiving can be emotionally and financially costly.69 In the United States, the average lifetime income-related losses (lost wages, Social Security benefits, and pensions) associated with caregiving exceed $300,000 per caregiver.70

Unreimbursed deductibles and copayments for rehabilitation, nursing home care, and home health care, as well as modifications required for living with a disability, also add to patient costs.1,71 These include items such as handrails, wheelchair ramps, and wheelchair transportation. In 2012, the average annual cost for nursing home care was $90,520 for a private room and $81,030 for a semiprivate room.72 Because Medicare limits nursing home payments to 100 days, lengthy stays represent a considerable patient cost.72 The purchase price of a wheelchair-accessible van is $30,000 to $40,000, while a minivan wheelchair conversion costs $13,000 to $17,000.73

Patient outcomes associated with amputation are dismal and compare unfavorably to endovascular revascularization. After amputation, only 18% to 24% of patients are routinely discharged home, while the majority of patients (70%) go to another institution (a nursing home, rehabilitation facility, or other long-term care facility).74,75 Sixty percent to 80% are unable to walk.37 One-third or more experience depression, and in some, severe depression with suicidal ideation.1,76 The 2-year mortality rate is 30% to 50%,77-79 and contralateral amputation occurs in 36% to 50%.1,76

In contrast, after endovascular revascularization, almost two-thirds of patients are routinely discharged home, and less than 20% are discharged to a nursing home.80 At 2 years, 80% are walking, and almost 90% are living independently.81 In recent studies, 2-year mortality is 16% to 24%.82-84 However, reintervention is required in 30% to 40%.1,35,85,86

Additional adverse amputation outcomes include a lengthy healing process, reduced quality of life, chronic pain, and skin problems in the stump. At 100 days, 45% of BKAs and 24% of AKAs have not healed.87 Amputees perceive themselves to be severely impaired in ambulation, body care, movement, and mobility.88 Chronic pain is experienced by almost all amputees (not just phantom limb pain—which occurs at a rate of 80%—but also residual limb pain in up to 74% of patients, and back pain in 50%–60%).89,90 Skin problems in the stump occur in 15% to 40%, resulting in reduced prosthetic use, as well as shorter walking distance if using a prosthetic.91-93

Perler writes, “The rationale for primary amputation assumes that patients will ambulate successfully with a prosthesis. . .”59 In reality, many patients are not even successfully fitted for a prosthesis, and thus are not able to walk. A population-based study of all major lower limb amputees aged 65 and older in Olmstead County, Minnesota, found that barely more than one-third of patients were successfully fitted for a prosthesis. Forty-seven percent of BKA patients and only 15% of AKA patients were fitted. The major reason for not being fitted was death. Additional reasons included reamputation, presence of cerebrovascular disease, cognitive deficits, and skin integrity.94

Referral studies have reported fitting rates of 60% to 90%.94 However, because of potential bias in referral studies, the assumption that the majority of elderly, dysvascular amputees ambulate may be incorrect. Patients referred to specialized fitting clinics tend to be younger, expected to do well, with fewer comorbidities, and more likely to have a BKA.94


Although research is limited, available evidence indicates that treating CLI patients with primary amputation is not cost-effective and economically represents a misallocation of United States health care resources.

In order to obtain more accurate CLI cost estimates, additional data are needed on direct patient costs and the total hospital costs of different therapies (procedure costs plus mortality, morbidity, and revisions). Cost and additional quality-of-life data are also needed for patient groups believed to be best served with specific therapies. Several studies have concluded that primary amputation might be the best therapy in certain patient groups (those who have dementia or are institutionalized or nonambulatory, etc).40,87,95 However, the economic impact is unknown, because costs were not included. For example: Is it more expensive to care for a nursing home patient with an AKA than one with both limbs intact? What are the costs to the patient and family?

Finally, the cost-effectiveness of preventive care in CLI remains largely unexplored. This includes an economic analysis of costs and benefits of broader utilization of risk factor modification therapies to prevent cardiovascular morbidity and mortality, as well as the potential impact of earlier CLI diagnosis and treatment. Another important area of economic investigation relates to the cost and effect of early revascularization on survival.

Mary L. Yost, MBA, is President of The Sage Group LLC Research and Consulting in Atlanta, Georgia. She may be reached at (404) 816-0746; yost@thesagegroup.us. The Sage Group LLC is a for-profit research and consulting company specializing in vascular disease in the lower limbs, including peripheral artery disease, intermittent claudication, CLI, acute limb ischemia, diabetic foot ulcer, and amputation. She has no financial interests related to this article, but the major clients in the last year included Baxter, Cardiovascular Systems, Inc., Novadaq Technologies, Spectranetics, and The Medicines Company. The author discloses stock holdings in Abbott Laboratories, Inc., AbbVie Inc., AngioDynamics Inc., and Derma Sciences, Inc.

  1. Allie DE, Hebert CJ, Lirtzman MD, et al. Critical limb ischemia: a global epidemic. A critical analysis of current treatment unmasks the clinical and economic costs of CLI. Eurointervention, 2005;1:60-69.
  2. Goodney PP, Travis LL, Nallamothu BK, et al. Variation in the use of lower extremity vascular procedures for critical limb ischemia. Cardiovasc Qual Outcomes. 2012;5:94-102.
  3. Number (in Thousands) of Hospital Discharges for Nontraumatic Lower Extremity Amputation with Diabetes as a Listed Diagnosis, United States, 1988–2009. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics, Division of Health Care Statistics, data from the National Hospital Discharge Survey. http://www.cdc.gov/diabetes/statistics/ lea/fig1.htm. Accessed October 2012.
  4. Yost ML. Peripheral artery disease interventional market analysis based on treatment with angioplasty or atherectomy. Atlanta (GA): The Sage Group; 2012.
  5. Henry AJ, Hevelone ND, Belkin MB, et al. Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. J Vasc Surg. 2011;53:330-9.e1.
  6. Baser O, Verpillat P, Gabriel S, et al. Prevalence, incidence, and outcomes of critical limb ischemia in the US Medicare population. Vasc Dis Mgmt. 2013:10;E26-36.
  7. Goodman DC, Brownlee S, Chang C, et al. Regional and racial variation in primary care and the quality of care among Medicare beneficiaries. A report of the Dartmouth Atlas Project. The Dartmouth Institute for Health Policy and Clinical Practice. http://www.dartmouthatlas.org/downloads/reports/Primary_care_report_090910.pdf. Published September 9, 2010.
  8. Eslami MH, Zayaruzny M, Fitzgerald GA. The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia. J Vasc Surg. 2007;45:55-59.
  9. Holman KH, Henke PK, Dimick JB, et al. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54:420-426.
  10. Regenbogen SE, Gawande AA, Lipsitz SR, et al. Do differences in hospital and surgeon quality explain racial disparities in lower-extremity vascular amputations? Ann Surg. 2009;250:424-431.
  11. Rowe VL, Weaver FA, Lane JS, et al. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010;51:21S-26S.
  12. Rucker-Whitaker C, Feinglass J, Pearce WH. Explaining racial variation in lower extremity amputation: a 5-year retrospective claims data and medical record review at an urban teaching hospital. Arch Surg. 2003;138:1347-1351.
  13. Guadagnoli E, Ayanian JZ, Gibbons G, et al. The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities. Arch Surg. 1995;130:381-386.
  14. Collins TC, Johnson M, Henderson W, et al. Lower extremity nontraumatic amputation among veterans with peripheral arterial disease: is race an independent factor? Med Care 2002;40:I106-16.
  15. Morrissey NJ, Giacovelli J, Egorova N, et al. Disparities in the treatment and outcomes of vascular disease in Hispanic patients. J Vasc Surg. 2007;46:971-978.
  16. Margolis DJ, Hoffstad O, Nafash J, et al. Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care. 2011;34:2363-2367.
  17. Jones WS, Patel M, Dai D, et al. Geographic variation of lower extremity amputation in patients with peripheral artery disease: results from U.S. Medicare 2000-2008. J Am Coll Cardiol. 2012;59:E1670.
  18. Wrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care. 2001;24:860-864.
  19. Anonymous. The diabetic amputation lottery. Drug Ther Bull. 2011;49:97.
  20. Goodney PP, Holman K, Henke PK, et al. Regional intensity of vascular care and lower extremity amputation rates. J Vasc Surg. 2013;57:1471-1479.
  21. Barshes NR, Sigireddi M, Wrobel JS, et al. The system of care for diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle. 2013;4. doi: 10.3402/dfa.v4i0.21847. eCollection 2013.
  22. Abou-Zamzam, AM. Lower extremity amputation: indications, patient evaluation, and level determination. In: Rutherford, RB, editor. Vascular Surgery. 6th ed. Philadelphia (PA): Elsevier Saunders; 2005:2452-2459.
  23. Nehler MR, Wolford H. Amputation: an overview. In: Rutherford. Vascular Surgery. 2005:2447-2452.
  24. Vemulapalli S, Greiner MA, Jones WS, et al. Peripheral arterial testing before lower extremity amputation among Medicare beneficiaries, 2000 to 2010. Circ Cardiovasc Qual Outcomes. 2014;7:142-150.
  25. Palena LM, Brocco E, Manzi M. The clinical utility of below-the-ankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheter Cardiovasc Interv. 2014;83:123-129.
  26. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368-1375.
  27. Hasanadka R, McLafferty RB, Moore CJ, et al. Predictors of wound complications following major amputation for critical limb ischemia. J Vasc Surg. 2011;54:1374-1382.
  28. Belmont PJ, Davey S, Orr JD, et al. Risk factors for 30-day postoperative complications and mortality after belowknee amputation: a study of 2,911 patients from the national surgical quality improvement program. J Am Coll Surg. 2011;213:370-378.
  29. Aulivola B, Hile CM, Hamdan AD, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139:395-399.
  30. Stone PA, Flaherty SK, Hayes JD, et al. Lower extremity amputation: a contemporary series. W V Med J. 2007;103:14-18.
  31. Collins TC, Nelson D, Ahluwalia JS. Mortality following operations for lower extremity peripheral arterial disease. Vasc Health Risk Manag. 2010;6:287-296.
  32. Khuri SF, Henderson WG, DePlama RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326-343.
  33. Vogel TR, Dombrovsky VY, Haser PB, et al. Evaluating preventable adverse safety events after elective lower extremity procedures. J Vasc Surg. 2011;54:706-713.
  34. DeRubertis BG. Shifting paradigms in the treatment of lower extremity vascular disease. A report of 1000 percutaneous interventions. Ann Surg. 2007;246:415-424.
  35. Sachs T, Pomposelli F, Hamdan A, et al. Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft. J Vasc Surg. 2011;54:1021-1031.
  36. Muradin GSR, Hunink MGM. Cost and patency rate targets for the development of endovascular devices to treat femoropopliteal arterial disease. Radiology. 2001;218:464-469.
  37. Dormandy JA, Rutherford RB. Management of peripheral arterial disease (PAD). TransAtlantic Inter-Society Consensus (TASC) Working Group. TASC document. J Vasc Surg. 2000;31:S1-S296.
  38. Boltz MM, Hollenbeak CS, Julian KG, et al. Hospital costs associated with surgical site infections in general and vascular surgery. Surgery. 2011;150:934-942.
  39. Schneider PA. Endovascular surgery in the management of chronic lower extremity ischemia. In: Rutherford Vascular Surgery. 2005:1192-1222.
  40. Taylor SM, Kalbaugh CA, Cass AI, et al. “Successful outcome” after below knee amputation: an objective definition and influence of clinical variables. Am Surg. 2008;74:607-612.
  41. Toursarkissian B, Shireman PK, Harrison A, et al. Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution. Am Surg. 2002;68:606-610.
  42. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil. 2005;86:480-486.
  43. O'Brien PJ, Cox MW, Shortell CK, et al. Risk factors for early failure of surgical amputations: an analysis of 8,878 isolated lower extremity amputation procedures. J Am Coll Surg. 2013;216:836-842.
  44. Yeager RA, Moneta, GL, Edwards JM, et al. Deep vein thrombosis associated with lower extremity amputation. J Vasc Surg. 1995;22:612-615.
  45. Zickler RW, Gahtan V, Matsumoto T, et al. Deep venous thrombosis and pulmonary embolism in bilateral lowerextremity amputee patients. Arch Phys Med Rehabil. 1999;80:509-511.
  46. Nowygrod R, Egorova N, Greco G, et al. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006;43:205-216.
  47. Egorova N, Guillerme S, Gelijns A, et al. An analysis of the outcomes of a decade of experience with lower extremity revascularization including limb salvage, lengths of stay, and safety. J Vasc Surg. 2010;51:878-885.
  48. Elixhauser A, Andrews RM. Profiles of inpatient operating room procedures in US hospitals. Arch Surg. 2010;145:1201- 1208.
  49. Yost ML. The economic cost of dysvascular amputation. Atlanta (GA): The Sage Group. In press.
  50. HCUP Query. Outcomes by patient and hospital characteristics for ICD-9 procedure codes 84.14-84.17. 2011 National statistics. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup.ahrq.gov/. Accessed December 29, 2013.
  51. Tennvall GR, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis. 2004;39:S132-139.
  52. Barshes NR, Chambers JD, Cantor SB, et al. A primer on cost-effectiveness analyses for vascular surgeons. J Vasc Surg. 2012;55:1794-1800.
  53. Barshes NR, Chambers JD, Cohen J, et al. Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss. J Vasc Surg. 2012;56:1015-1024.
  54. Brothers TE, Rios GA, Robison JG, et al. Justification for intervention for limb-threatening ischemia: a surgical decision analysis. Cardiovasc Surg. 1999;7:62-69.
  55. Mahoney EM, Wang K, Keo HH, et al. Vascular hospitalization rates and costs in patients with peripheral artery disease in the United States. Circ Cardiovasc Qual Outcomes. 2010;3:642-651.
  56. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia. Surgery. 1986;99:26- 35.
  57. Gupta SK, Veith FJ, Ascer E, et al. Cost factors in limb-threatening ischaemia due to infrainguinal arteriosclerosis. Eur J Vasc Surg. 1988;2:151-154.
  58. Raviola CA, Nichter LS, Baker JD, et al. Cost of treating advanced leg ischemia. Bypass graft versus primary amputation. Arch Surg. 1988;123:495-496.
  59. Perler BA. Cost-efficacy issues in the treatment of peripheral vascular disease: primary amputation or revascularization for limb-threatening ischemia. J Vasc Interv Radiol. 1995;6:111S-115S.
  60. HCUP Query. Outcomes by ICD-9-CM procedure code(s) 84.14-84.17. Procedure costs. 2010 National statistics. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://www. hcup.ahrq.gov/. Accessed September 17, 2012.
  61. HCUP Query. Outcomes by ICD-9-CM procedure code(s) 39.50, 39.90 & 00.55. Procedure costs. 2010 National statistics. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://www. hcup.ahrq.gov/. Accessed September 17, 2012.
  62. Jansen RMG, de Vries SO, Cullen KA, et al. Cost-identification analysis of revascularization procedures on patients with peripheral arterial occlusive disease. J Vasc Surg. 1998;28:617-623.
  63. Flu H, van der Hage JH, Knippengerg B, et al. Treatment of peripheral arterial obstructive disease: an appraisal of the economic outcome of complications. J Vasc Surg. 2008;48:368-376.
  64. Davenport DL, Henderson WG, Khuri SF, et al. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications. Ann Surg. 2005;242:463-471.
  65. Fuller RL, McCullough EC, Bao MZ, et al. Estimating the costs of potentially preventable hospital acquired complications. Health Care Financing Review. 2009;30:17-32.
  66. Henry AJ, Hevelone ND. Hawkins AT, et al. Factors predicting resource utilization and survival after major amputation. J Vasc Surg. 2013;57:784-790.
  67. Jencks SF, Williams MV, Coleman EA. Rehospitalizations in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-1428.
  68. Weiss AJ, Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Procedure, 2010: Statistical Brief #154. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research (US), 2013 Apr. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf. Accessed March 2014.
  69. Genworth. A way forward: highlights from beyond dollars 2013. http:// www.genworth.com. Accessed March 2014.
  70. The MetLife study of working caregivers and employer health care costs. MetLife 2010. https://www.metlife.com/ mmi/research/working-caregiver-employer-health-care-costs.html#findings. Accessed March 2014.
  71. Barshes NR, Belkin M. A framework for the evaluation of “value” and cost-effectiveness in the management of critical limb ischemia. J Am Coll Surg. 2011;213:552-566.
  72. National Health Policy Forum. The basics: national spending for long term services and supports (LTSS) 2011. The George Washington University. Washington, DC. http://www.nhpf.org/library/the-basics/Basics_LTSS_02-01-13.pdf. Published February 1, 2013.
  73. America's #1 Mobility Solution. Web site. http://www.aavans.com/Vehicles/AMSFAQ.aspx#1. Accessed March 2014.
  74. HCUP Query. Discharge status for amputation for circulatory system disorders except upper limb and toe, DRG 239, 240 and 241. 2010 National statistics. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup.ahrq.gov/. Accessed June 2012.
  75. Dillingham TR, Yacub JN, Pezzin LE. Determinants of postacute care discharge destination after dysvascular lower limb amputation. PM R. 2011;3:336-344.
  76. Yeager RA. Lower extremity amputation: perioperative complications. In: Rutherford Vascular Surgery. 2005:2474- 2481.
  77. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC) II. J Vasc Surg. 2007;45:S1-S67.
  78. Gardner SJ, Huang C, Singh H, et al. Amputation as a last resort. Endovasc Today 2011;10:38-44.
  79. Subramaniam B, Pomposelli F, Talmor D, et al. Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics. Anesth Analg. 2005;100:1241-1247.
  80. HCUP Query. Discharge status for other vascular procedures DRG 252, 253 and 254. 2010 National statistics. HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup.ahrq. Accessed June 2012.
  81. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. Determinants of functional outcome after revascularization for critical limb ischemia: an analysis of 1000 consecutive vascular interventions. J Vasc Surg. 2006;44:747-756.
  82. Conrad MF, Crawford RS, Hackney LA, et al. Endovascular management of patients with critical limb ischemia. J Vasc Surg. 2011;53:1020-1025.
  83. Aiello FA, Khan AA, Meltzer AJ, et al. Statin therapy is associated with superior clinical outcomes after endovascular treatment of critical limb ischemia. J Vasc Surg. 2012;55:371-379.
  84. Abularrage CJ, Conrad MF, Hackney LA, et al. Long-term outcomes of diabetic patients undergoing endovascular infrainguinal interventions. J Vasc Surg. 2010;52:314-322.
  85. Bradbury AW, Adam DJ, Bell J, et al. Bypass vs angioplasty in severe ischemia of the leg (BASIL) trial: an intention to treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplastyfirst revascularization strategy. J Vasc Surg. 2010;51:5S-17S.
  86. Vogel TR, Symons RG, Flum DR. A population-level analysis: the influence of hospital type on trends in use and outcomes of lower extremity angioplasty. Vasc Endovasc Surg. 2008;42:12-18.
  87. Nehler MR, Coll JR, Hiatt WR, et al. Functional outcome in a contemporary series of major lower extremity amputations. J Vasc Surg. 2003;38:7-14.
  88. Peters EJG, Harkless LB, Childs MR, et al. Functional status of persons with diabetes-related lower-extremity amputations. Diabetes Care. 2001;24:1799-1804.
  89. Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain and back pain in amputees: results of a national survey. Arch Phys Med Rehabil. 2005;86:1910-1919.
  90. Ehde DM, Czerniecki JM, Smith DG, et al. Chronic phantom sensations, phantom pain, residual limb pain and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000;81:1039-1044.
  91. Meulenbelt HEJ, Geertzen JH, Jonkman MF, et al. Skin problems of the stump in lower limb amputees: a clinical study. Acta Derm Venereol. 2011;91:173-177.
  92. Dudek NL, Marks MB, Marshall SC, et al. Dermatologic conditions associated with use of a lower-extremity prosthesis. Arch Phys Med Rehabil. 2005;86:659-63.
  93. Bui KM, Raugi GJ, Nguyen VQ, et al. Skin problems in individuals with lower-limb loss: literature review and proposed classification system. J Rehabil Res Dev. 2009;46:1085-1090.
  94. Fletcher DD, Andrews KL, Butters MA, et al. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil. 2001;82:776-779.
  95. Taylor SM, Kalbaugh CA, Blackhurst DW, et al. A comparison of percutaneous transluminal angioplasty versus amputation for critical limb ischemia in patients unsuitable for open surgery. J Vasc Surg. 2007;45:304-310.