Economic impact of limb-salvage strategies in chronic limb-threatening ischaemia: modelling and budget impact study based on national registry data.

BACKGROUND: Missed opportunities to reduce numbers of primary major lower-limb amputation and increase limb-salvage procedures when treating chronic limb-threatening ischaemia have previously been identified in the literature. However, the potential economic savings for healthcare providers when salvaging a chronic limb-threatening ischaemia-affected limb have not been well documented. METHODS: A model using National Health Service healthcare usage and cost data for 1.6 million individuals and averaged numbers of primary surgical procedures for chronic limb-threatening ischaemia from England and Wales in 2019-2021 was created to perform a budget impact analysis. Two scenarios were tested: the averaged national rates of major lower-limb amputation (above the ankle joint), angioplasty, open bypass surgery or arterial endarterectomy in the National Vascular Registry (current scenario); and revascularization rates adjusted based on the lowest amputation rate reported by the National Vascular Registry at the time of the study (hypothetical scenario). The primary outcome was the net impact on costs to the National Health Service over 12 months after the index procedure. RESULTS: In the current scenario, the proportions of different index procedures were 10% for lower-limb major amputation, 55% for angioplasty, 25% for open bypass surgery and 10% for arterial endarterectomy. In the hypothetical scenario, the procedure rates were 3% for major lower-limb amputation, 59% for angioplasty, 27% for open bypass surgery and 11% for arterial endarterectomy. For 16 025 index chronic limb-threatening ischaemia procedures, the total care cost in the current scenario was €243 924 927. In the hypothetical scenario, costs would be reduced for index procedures (-€10 013 814), community care (-€633 943) and major cardiovascular events (-€383 407), and increased for primary care (€59 827), outpatient appointments (€120 050) and subsequent chronic limb-threatening ischaemia-related surgery (€1 179 107). The net saving to the National Health Service would be €9 645 259. CONCLUSION: A shift away from primary major lower-limb amputation towards revascularization could lead to substantial savings for the National Health Service without major cost increases later in the care pathway, indicating that care decisions taken in hospitals have wider benefits.

Clinical outcomes of acute limb ischaemia caused by femoropopliteal stent thrombosis.

BACKGROUND: Although femoropopliteal-specific stents have durable patency, stent thrombosis (ST) may occur, which can lead to acute limb ischaemia (ALI). AIMS: We aimed to investigate the clinical features and outcomes of ALI caused by femoropopliteal ST in patients with lower extremity artery disease. METHODS: This multicentre retrospective study included 499 patients with ALI - of whom 108 patients had ALI caused by femoropopliteal ST (ST-ALI) and 391 patients had ALI caused by other aetiologies (de novo ALI) - who underwent treatment between September 2011 and March 2023. Clinical features and outcomes were compared between the two groups. The primary outcome measure was 12-month amputation-free survival; factors associated with amputation or death were investigated using multivariate Cox proportional hazards regression analysis. RESULTS: Patients with ST-ALI were significantly more likely to exhibit conventional atherosclerotic risk factors, including diabetes mellitus (63% vs 26%) and haemodialysis (51% vs 10%) compared to patients with de novo ALI, whereas patients with de novo ALI were older (80 years vs 74 years) and more likely to have atrial fibrillation (49% vs 18%) than patients with ST-ALI. The 12-month amputation-free survival rate was significantly lower in the ST-ALI group than that in the de novo ALI group (51% vs 76%; p<0.001). Multivariate analysis revealed that ST-ALI, older age, haemodialysis, atrial fibrillation, the presence of a wound, peak C-reactive protein level, and non-ambulatory status all have an independent, positive association with death or major amputation. CONCLUSIONS: The current study revealed that patients with ST-ALI had worse clinical outcomes than those with de novo ALI, highlighting the need to maximise ST prevention.

Endovascular clot removal in small and tortuous arteries: a case series.

Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device.

Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia.

Chronic limb-threatening ischemia is defined as ischemic rest pain or tissue loss (eg, ulceration/gangrene) that has been present for greater than 2 weeks. Workup includes a careful history, physical examination focused on evaluation of pulses and wounds, lower extremity noninvasive vascular studies (eg, ankle-brachial indices, toe pressures), saphenous vein mapping, and imaging of the lower extremity arterial anatomy (eg, computed tomography, magnetic resonance, or subtraction angiography) if a revascularization intervention is planned.

Endograft Collapse after Standard Endovascular Aneurysm Repair Implantation: A Report of Two Cases.

Endovascular aneurysm repair (EVAR) has emerged as the preferred treatment for abdominal aortic aneurysm (AAA), offering advantages such as reduced mortality, faster recovery, and fewer complications compared to open repair (OR). However, concerns persist regarding long-term durability, and the need for reinterventions. Among all reported EVAR complications, endograft collapse poses a significant challenge, particularly when presenting with acute lower limb ischemia (ALI). The aim of this report is to describe two cases of non-dissection-related abdominal endograft collapse manifesting as ALI, requiring urgent intervention, emergent conversion to OR and complete endograft removal.

Surgical Interventions for Acute Limb Ischaemia (ALI).

OBJECTIVE: To evaluate presentations, aetiologies, interventions, and outcomes of patients presenting with acute limb ischaemia (ALI). STUDY DESIGN: An observational study. Place and Duration of the Study: Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2000 to December 2020. METHODOLOGY: Record of 104 patients who underwent surgical interventions for ALI was retrospectively evaluated. The diagnosis was confirmed on imaging (ultrasound / CTA / conventional angiography). Demographic characteristics, co-morbidities, aetiologies, and outcomes were analysed using descriptive statistics and logistic regression. RESULTS: The cohort's mean age was 58.89 ± 12.6 years, with (54.8%, n = 57) females and (45.2%, n = 47) males. Hypertension (54.8%, n = 57), diabetes (46.2%, n = 48), and atrial fibrillation (34.6%, n = 36) were common comorbidities. Thromboembolism (67.3%, n = 70) and thrombotic occlusion (32.7%, n = 34) were primary aetiologies, predominantly affecting the lower limb (66.3%, n = 58) and femoral artery (51.9%, n = 54). The majority of cases were classified as Rutherford classification 2A (53.8%; 56 cases) and 2B (44.2%; 46 cases); 58 (55.8%) patients were classified as ASA Class III, while 36 (34.6%) patients were categorised as ASA Class IV. Embolectomy (80.8%, n = 84) was the prevailing intervention, with an amputation rate (17.3%, n = 18) and a mortality rate (5.8%, n = 6). CONCLUSION: Most patients with ALI presented with Rutherford Class II and had thromboembolism aetiology. Embolectomy was the most commonly performed procedure with a high amputation rate and mortality. KEY WORDS: Acute limb ischaemia, Embolectomy, Amputation, Thromboembolism.

Recurrent Acute Limb Ischemia and Successful Treatment with Endovascular Thrombectomy.

Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events; however, many patients with AF are noncompliant with medication regimens, which increases said risk substantially. Suboptimal health literacy presents significant hurdles to compliance with medical treatment. Here we present a case of an elderly Hispanic woman with AF and several comorbidities, including a history of dementia, who presented with consecutive recurrence of acute limb ischemia in the bilateral lower extremities just 3 days apart. Both events were successfully treated with endovascular thrombectomy. This case study not only showcases the efficacy of the latest endovascular technologies, but also draws attention to the importance of strict patient medication adherence in AF and the effects that health literacy can have on said adherence.

Free Flap Perfusion in Microvascular Head and Neck Reconstruction: Influence of the Number of Ischemia Intervals and Ischemia Duration-A Retrospective Study.

BACKGROUND: In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion. METHODS: Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration. RESULTS: Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis. CONCLUSIONS: The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.

Clinical outcomes of the Burnett "snake" maneuver shunt modification for ischemic priapism.

BACKGROUND: Major ischemic priapism (IP) is defined as a persistent penile erection for >4 hours. IP may cause serious complications, especially if prompt resolution is not achieved. Therefore, selecting the most effective and usable shunt technique is crucial in IP cases that are refractory to medical therapy. AIM: To compare the effectiveness and complication risks of distal corporoglanular shunt procedures with and without the Burnett "snake" maneuver. METHODS: We conducted a retrospective study of patients who presented with IP and underwent surgical treatment at our institution between 2005 and 2021. The patients were categorized into 2 groups: group 1 (n = 26) underwent distal shunt + Burnett snake maneuver, and group 2 (n = 56) underwent distal shunt-only. Clinical history, parameters of IP, details of medical and surgical treatments, and follow-up information were evaluated. OUTCOMES: Outcomes included differences in IP resolution and recurrence, functional erections, and complications between corporoglanular shunt procedures with and without the Burnett snake maneuver. RESULTS: In group 1, 24 of 26 patients (92.3%) experienced priapism resolution with a single surgical intervention, while this outcome was observed in 30 of 56 patients (53.6%) in group 2 (P < .001). Notably, priapism recurrence was significantly lower in group 1, occurring in 1 of 24 patients (4.2%), as opposed to 8 of 30 patients (26.6%) in group 2 (P < .001). Of the patients with documented sexual function status at follow-up, functional erections (capable of penetration with or without phosphodiesterase 5 inhibitors) were noted in 6 of 14 patients (42.8%) in group 1 and 13 of 26 patients (50%) in group 2 (P = .66). CLINICAL IMPLICATIONS: This study provides valuable insights regarding technical aspects of distal shunt procedures with and without the Burnett snake maneuver for treating major IP episodes. These results can help surgeons with clinical decision making for patients who present with IP. STRENGTH AND LIMITATIONS: Limitations include the single-site retrospective design with potential selection bias, inaccuracies in medical record data, challenges in controlling confounding variables, and the lack of validated questionnaire scores for erectile function evaluation. CONCLUSION: Our study demonstrates that modifying distal shunt procedures using the Burnett snake maneuver significantly improves priapism resolution and effectively prevents further priapism episodes without introducing additional complications or erectile function loss, thereby distinguishing it from distal shunt-only procedures.

Use of perfusion device for free flap salvage after ischemia in swine.

INTRODUCTION: In free flap reconstruction, improving flap tolerance to warm ischemia (WI) is fundamental. WI is the result of a venous or arterial thrombosis, which can only be addressed through surgical revision. No additional treatments have shown superior efficacy at salvaging free flaps after or during WI. Custom perfusion machines (PM), used to reduce the intensity of lesions of the flap stored in cold ischemia, have not been evaluated for WI flap salvage. This proof-of-concept study assessed whether the Lifeport® perfusion machine could improve the salvage procedure's success rates after one hour of venous WI. METHODS: Five different groups were evaluated with four porcine latissimus dorsi free flaps included in each group. Depending on the group, the flaps were subjected to one hour of WI followed by revascularization, static hypothermic submersion, or dynamic Lifeport® perfusion. Additionally, two flap perfusion liquids were evaluated: KPS-1® and IGL-1®. Biopsies were performed before in vivo warm ischemia of the flap, after in vivo warm ischemia of the flap, and after one and two hours of preservation. Interstitial edema, muscular cell size and muscular diffuse necrosis were quantified by histological assessment. RESULTS: Static submersion did not demonstrate any efficacy for venous flap salvage. Dynamic perfusion on Lifeport® machine showed a significant improvement in tissue parameters. Thrombi and fibrine, present during the WI period, were no longer visible inside vessels and the perfusion machine flow evacuated the inflammatory cells and their substrates from the flap. The flap weights did not increase during perfusion time, confirming the benefits of the Lifeport® perfusion machine. CONCLUSION: Evaluating Lifeport® advantages on human free flap salvage is necessary to confirm the benefits for the tissue and to increase post-operative results after congestive free flap revision surgery.

The Modified Albumin-Bilirubin (ALBI) Grade Reflect the Fate of Limb Prognosis in Patients with Chronic Limb-Threatening Ischemia.

BACKGROUND: To examine the influence of liver function on patients with chronic limb-threatening ischemia (CLTI), we classified patients with CLTI after revascularization according to their modified albumin-bilirubin (ALBI) grades. METHODS: We retrospectively analyzed single-center data of patients who underwent revascularization for CLTI between 2015 and 2020. Patients were classified with ALBI grades 1, 2a, and 2b and 3 according to the ALBI score, which was calculated, based on serum albumin and total bilirubin levels. The endpoints were the 2-year amputation-free survival (AFS) and 1-year wound healing rates. RESULTS: We included 190 limbs in 148 patients, and 50, 54, and 86 cases were assigned as grade 1, 2a, and 2b and 3, respectively. The 2-year AFS rates for the grade 1, 2a, and 2b and 3 groups were 79 ± 6%, 66% ± 7%, and 45 ± 6%, respectively (P < 0.01). One-year cumulative wound healing rates for grade 1, 2a, and 2b and 3 groups were 68 ± 7%, 69% ± 6%, and 48% ± 5%, respectively (P = 0.01). Multivariate Cox proportional hazard analyses identified age (≥75 years), dependent ambulatory status, and modified ALBI grades 2b and 3 compared with grades 1 and 2a as significant independent predictors of AFS. The dependent ambulatory status and Wound, Ischemia, and foot Infection classification stage 4 were significant negative predictors of wound healing. CONCLUSIONS: Many patients with CLTI had high modified ALBI grades, and impaired liver function classified as modified ALBI grade 2b and 3 is a robust negative predictor of AFS.

Long-Term Outcome of Lower Extremity Bypass Surgery in Patients with Chronic Kidney Disease and Critical Limb Ischemia in Germany.

BACKGROUND: The aim of this study is to present short- and long-term outcomes after lower extremity bypass (LEB) surgery in patients with chronic limb-threatening ischemia and chronic kidney disease (CKD), differentiated by peripheral artery disease (PAD) Fontaine stage III and IV. METHODS: Retrospective analysis of anonymized data from a nationwide German health insurance company (AOK). Data from 22,633 patients (14,523 men) who underwent LEB from 2010 to 2015 were analyzed, presenting 18,271 with CKD stage 1/2, 2,483 patients with CKD stage 3, and 1,879 with CKD stage 4/5. RESULTS: Perioperative mortality (60-day mortality) was 7.2% for CKD stage 1/2, 12.4% for CKD stage 3, and 19.8% for CKD stage 4/5. Patients with PAD stage IV had significantly higher perioperative mortality (10.3%) than patients with PAD stage III (4.5%). The perioperative major amputation rate depended significantly on PAD stage IV (odds ratio [OR]: 2.57 confidence interval [CI]: 2.16-3.05, P < 0.001), the LEB level below the knee and crural/pedal (OR: 2.49 CI: 2.14-2.90, P < 0.001), CKD stage 4/5 (OR: 1.28, CI: 1.06-1.54, P = 0.009), and the presence of diabetes mellitus type 2 (OR: 1.19, CI: 1.05-1.36, P = 0.007). Kaplan-Meier estimated long-term survival of up to 9 years after surgery was 31.7% for patients with CKD stage 1 and 2, 14.3% for CKD stage 3, and only 10.1% for CKD stage 4 and 5 (P < 0.001). PAD Fontaine stage IV versus III (hazard ratio: 1.64, CI: 1.56-1.71, P < 0.001), but not bypass level, had an independent adverse influence on long-term survival. CONCLUSION: CKD and PAD stage were equally significant independent predictors of patient survival and major adverse cardiovascular events with higher PAD and CKD stages associated with less favorable long-term outcomes.

Controlled Reversible Visceral Arterial Ischemia, Venous Congestion and Combined Malperfusion via Midline Laparotomy in Rats.

Besides sepsis and malignancy, malperfusion is the third leading cause of tissue degradation and a major pathomechanism for various medical and surgical conditions. Despite significant developments such as bypass surgery, endovascular procedures, extracorporeal membrane oxygenation, and artificial blood substitutes, tissue malperfusion, especially of visceral organs, remains a pressing issue in patient care. The demand for further research on biomedical processes and possible interventions is high. Valid biological models are of utmost importance in enabling this kind of research. Due to the multifactorial aspects of tissue perfusion research, which include not only cell biology but also vascular microanatomy and rheology, an appropriate model requires a degree of biological complexity that only an animal model can provide, rendering rodents the obvious model of choice. Tissue malperfusion can be differentiated into three distinct conditions: (1) isolated arterial ischemia, (2) isolated venous congestion, and (3) combined malperfusion. This article presents a detailed step-by-step protocol for the controlled and reversible induction of these three types of visceral malperfusion via midline laparotomy and clamping of the abdominal aorta and caval vein in rats, underscoring the significance of precise surgical methodology to guarantee uniform and dependable results. Prime examples of possible applications of this model include the development and validation of innovative intraoperative imaging modalities, such as Hyperspectral Imaging (HSI), to objectively visualize and differentiate malperfusion of gastrointestinal, gynecological, and urological organs.

Minimally invasive surgical approach to model hypertrophic scarring in the rabbit ear.

BACKGROUND: Current strategies for hypertrophic scar prevention and treatment are limited. OBJECTIVE: To facilitate these efforts, a minimally invasive hypertrophic scar model was created in a rabbit ear for the first time based on previous methods used to induce ischemia. METHODS: Six New Zealand white rabbits (12 ears total) were studied. First, ischemia was achieved by ligating the cranial artery, cranial vein and central artery, while preserving the caudal artery, caudal vein and central vein, respectively. The relative level of ischemia induced at time of surgery, both baseline and maximum perfusion, was assessed with a fluorescent light-assisted angiography and demonstrated lower rates of perfusion in the ischemic ears. Following vascular injury, a 2-cm full thickness linear wound was created on the ventral ear and closed with 4 - 0 Nylon sutures under high tension. For each rabbit, one ear received a combination of ischemia and wounding with suture tension (n = 6), while the other ear was non-ischemic with wounding and suture tension alone (n = 6). RESULTS: Four weeks post-operatively, ischemic ears developed scar hypertrophy (histological scar thickness: 1.1 ± 0.2 mm versus 0.5 ± 0.1 mm, p < 0.05). CONCLUSION: Herein, we describe a novel, prototypical minimally invasive rabbit ear model of hypertrophic scar formation that can allow investigation of new drugs for scar prevention.

Changes in the Remaining Iliac Artery According to Retrograde Flow after Aorto-Femoral Bypass in Abdominal Aortic Aneurysms.

BACKGROUND: Considering a patient's anatomy and vascular conditions, aorto-femoral bypass is a treatment approach for the open repair of abdominal aortic aneurysms. This study aimed at evaluating changes in the remnant iliac artery and their correlation with the preservation state of retrograde flow from femoral anastomosis. METHODS: Of 221 patients who underwent abdominal aortic aneurysm surgery between 2007 and 2022 in Pusan National University Hospital, 29 patients who underwent aorto-femoral bypass were included in this retrospective cohort study. Of these patients, 21 underwent aortobifemoral bypass and 8 underwent aortoiliac-and-femoral bypass. The change in size of the iliac artery from preoperative to postoperative and whether this difference in size depended on the status of postoperative retrograde flow were investigated. Additionally, factors affecting overall mortality and ischemic complications were identified. RESULTS: The median duration from operation to the last follow-up was 2069.5 days (about 5.7 years). The average age of the patients was 78.1 years, and the proportion of males was 75.9%. In cases of disappearance of postoperative retrograde flow from the femoral anastomosis, the postoperative iliac artery size was significantly reduced compared to its preoperative size (18.4 ± 18.9 mm vs. 13.2 ± 7.9 mm, respectively; P = 0.04). The group with maintained retrograde flow had significantly larger residual common iliac artery size than the group with disappearance of flow. (20.0 ± 28.0 mm vs. 14.6 ± 8.5 mm, respectively; P = 0.02). Disappearance of retrograde flow was a significant factor in the iliac artery size reduction after surgery (odds ratio, 2.5; 95% confidence interval, 1.9-5.3; P = 0.02). Three patients with maintained retrograde flow (18.8%) required intervention owing to an increase in the size of the iliac artery. The factors that significantly influenced overall death as analyzed by Cox proportional hazard regression were chronic obstructive pulmonary disease (hazard ratio, 36.8; 95% confidence interval, 1.6-870.0; P = 0.03), peripheral arterial occlusive disease (hazard ratio, 12.7; 95% confidence interval, 1.4-115.8; P = 0.02), and disappearance of retrograde flow (hazard ratio, 8.7; 95% confidence interval, 1.2-63.9; P = 0.03). CONCLUSIONS: Among the open repair methods for abdominal aortic aneurysms, if retrograde flow was not maintained through femoral anastomosis when aorto-femoral bypass was performed, the size of the remaining iliac artery decreased. However, loss of retrograde flow increased long-term mortality. When aorto-femoral bypass is performed, regular imaging follow-up is necessary at appropriate intervals to check the remnant iliac artery and retrograde flow.

Heparin-Induced Thrombocytopenia After Revascularization of Gustilo-Anderson Type IIIC Open Lower Leg Fracture: A Case Report of Subsequent Ischemic Limb Salvage Failure.

BACKGROUND Heparin-induced thrombocytopenia (HIT) is a disease in which the immune response elicited by heparin results in a state of hypercoagulability and platelet activation, leading to thrombocytopenia and thromboembolism. Gustilo-Anderson type IIIC open fractures of the extremities are defined as open fractures presenting with arterial injuries that require repair and result in treatment challenges and complications. The diagnosis of HIT can be difficult in patients with severe trauma with consumptive thrombocytopenia associated with heavy bleeding and the use of heparin after vascular anastomosis. CASE REPORT A 48-year-old man was injured in a car accident, pinching his right lower leg and sustaining a Gustilo-Anderson type IIIc open fracture, for which he underwent emergency revascularization surgery. Heparin was administered continuously immediately after the surgery. On postoperative day 9, ischemic changes were observed in the right foot, and we performed suture re-anastomosis; however, the blood circulation in the right lower leg did not resume, and right lower leg amputation was performed due to ischemic necrosis with the onset of HIT. Postoperatively, the patient was switched to edoxaban after the recovery of his platelet count. Thereafter, the patient experienced no new thrombus occlusion or wound trouble, and was able to walk on a prosthetic leg and return to daily life. CONCLUSIONS It is important to consider the possibility of HIT as soon as thrombocytopenia appears in patients with Gustilo-Anderson type IIIC open fracture who are receiving heparin after vascular anastomosis, as a delayed diagnosis of HIT can make it difficult to save the limb.

Staged treatment with arterial reconstruction and flap transplantation for ischemic mangled extremity: An observational study.

Patients with traumatic ischemic mangled extremities first undergo arterial reconstruction using autogenous vein grafts, followed by flap transplantation as a staged treatment for soft tissue reconstruction. This study aimed to report the outcomes of such a staged treatment. Thirteen patients underwent arterial reconstruction between February 2015 and April 2017 due to damage to the major blood vessels by the traumatic mangled extremities. Of them, 6 patients (5 males and 1 female with a mean age of 51 years, age range: 36-60 years) who underwent soft tissue reconstruction due to necrosis were retrospectively analyzed. The average Mangled Extremity Severity Score was 7.2 (range, 6-8). Injuries were found in the lower leg (4 cases), foot (1 case), and wrist and hand (1 case). Arterial reconstruction was performed using autologous venous grafts. The reconstructed arteries included the posterior tibial artery (3 cases), anterior tibial artery (1 case), dorsalis pedis artery (1 case), and radial artery (1 case). The blood circulation status of the reconstructed blood vessels was assessed using computed tomography angiography at an average of 5 weeks (range, 4-6 weeks) after arterial reconstruction. For some necrotic soft tissues, debridement and flap transplantation were performed an average of 7 weeks (range, 6-8 weeks) after arterial reconstruction. Soft tissue reconstruction was performed with an anterolateral thigh free flap in 4 cases, a local flap in 1 case, and a muscle flap in 1 case. In 5 out of 6 cases, blood circulation was maintained in the reconstructed blood vessels, resulting in the salvaging of the extremities. All the patients who underwent flap surgery survived. Notably, there were no special complications during a follow-up visit conducted at an average of 19 months post-reconstruction. To treat an ischemic mangled extremity, the limbs should first be salvaged with arterial reconstruction, followed by subsequent appropriate flap surgery when soft tissue necrosis occurs at the mangled site as a staged treatment.

Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality.

BACKGROUND: The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS: We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS: During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS: Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.