Internal Iliac Artery Patency as a Predictor of Above-Knee Amputation Stump Healing.

BACKGROUND: The primary aim of this study was to assess the role of internal iliac patency in predicting outcomes of above-knee amputation (AKA) stump healing. The secondary objectives were to assess the accuracy of Wound, Ischemia, and Foot Infection (WIfI) classification system in predicting AKA stump healing and its association with delayed mortality. METHODS: This is a retrospective study performed in a vascular surgery unit in a tertiary hospital on patients who underwent AKAs over 1 year, from July 2021 until June 2022. Patient demographic data, WIfI scoring, outcome of AKAs, and patency of profunda femoris and internal iliac artery (IIA) were collected. To minimize confounding, a single vascular surgeon performed all computed tomography imaging reviews and arterial measurements. Approval for this study was obtained from the National Research Registry, NMRR ID-23-01865-KQ4 (investigator initiated research). RESULTS: Ninety patients underwent AKA over 1 year, from July 2021 until June 2022. Occluded IIA in the presence of patent profunda femoris did not affect the wound healing of the AKA stump. There was significant association between WIfI scoring and mortality. Patients with a WIfI scoring of 3 to 4 were observed to have a higher mortality rate compared with patients with normal healing: 47 (72.0%) vs. 4 (80.0%); P = 0.021. CONCLUSIONS: In this study, the IIA patency shows no statistically significant effect on AKA stump healing; however, the small number of patients is a drawback of the study. This study also demonstrates that the WIfI score can be a prognostic factor for mortality in patients undergoing AKA.

Open axillary approach alternative access for stenting of external iliac total occlusion.

A primary endovascular approach is the mainstay of intervention for type C aortoiliac disease. When the femoral artery is unsuitable, upper extremity access can be critical in the setting of severe tortuosity or occlusive disease. The axillary artery represents alternative upper extremity access that may accommodate larger sheath sizes for therapeutic interventions. A 44-year-old gentleman with a history of right below-knee amputation was referred to the vascular unit with a left foot non-healing wound post wound debridement for diabetic foot ulcer. On examination, the left foot was non-salvageable with pitting oedema extended until knee level. Left lower limb pulses were non-palpable from femoral downwards. A biphasic signal was audible at the left femoral and monophasic at the popliteal. Photoplethysmography showed poor flow distally. Computed tomography angiogram revealed a 12 cm long segment total occlusion of the left external iliac artery just below the bifurcation of iliac vessel. On the right side, there was a long segment occlusion of the superficial femoral artery and calcified common femoral artery. The left axillary artery was used as an access and angioplasty was performed successfully. The advantages of upper extremity access in the axillary artery include the relatively large size and lower atherosclerotic burden. Larger profile stents for aortoiliac occlusion can easily be handled with a good strength through an axillary approach which is antegrade compared to a retrograde femoral approach. With the advancement of safety features of endovascular devices complications with an axillary approach have become less in the recent era.

Tuberculous aortic pseudoaneurysm treated with in situ silver-impregnated vascular inlay graft.

A 62-year-old man presented with continuous, persistent backache shortly after completion of antituberculosis medication for tuberculosis (TB) of the spine. Computed tomography scan revealed a pseudoaneurysm involving the infrarenal aorta. He was restarted on anti-TB medication and underwent repair of the pseudoaneurysm with an in situ silver-coated bifurcated Dacron graft. His postoperative recovery was uneventful and he remained well up to 12 months of follow up. To our knowledge, this is the first case in the literature where an in situ silver-impregnated vascular graft has been successfully used in treating a tuberculous pseudoaneurysm.