A Multidisciplinary Approach to End-Stage Limb Salvage in the Highly Comorbid Atraumatic Population: An Observational Study.

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success.

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis.

BACKGROUND: Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. METHODS: A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. RESULTS: Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. CONCLUSION: Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.

Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population.

BACKGROUND: In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. METHODS: Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. RESULTS: Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973). CONCLUSION: This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.

A hybrid approach to persistent sciatic artery fusiform aneurysm repair.

A persistent sciatic artery is a rare vascular anomaly that is prone to early atherosclerotic development and aneurysmal degeneration. Repair of the degenerative aneurysm is critical because it can lead to rupture, thrombosis, distal embolization, and sciatic nerve damage from compression. We report a case of a symptomatic unilateral persistent sciatic artery fusiform aneurysm that was treated using a simultaneous open surgical and endovascular approach. The patient underwent right common femoral to below-knee popliteal artery bypass and percutaneous endovascular embolization of the right sciatic artery aneurysm. Proper surgical intervention determined by the patient's comorbidities and unique anatomy achieved favorable outcomes.

Surgical management of pain or infection secondary to calciphylaxis: a wound center's experience and algorithmic multidisciplinary approach.

BACKGROUND: The role of surgical management of calciphylaxis remains understudied. OBJECTIVE: This article reports a case series and algorithmic approach to the multidisciplinary management of calciphylaxis. METHODS: A single-center retrospective review of all adult patients with calciphylaxis treated surgically between January 2010 and November 2022 was performed. RESULTS: Eleven patients met inclusion criteria. The average age was 50.9 years ± 15.8 SD, and most patients were female (n = 7 [63.6%]). Surgery was indicated for infection (n = 6 [54.5%]) and/or intractable pain (n = 11 [100%]). Patients underwent an average of 2.9 excisional debridements during their hospital course. Following the final excision, wounds were left open in 5 cases (29.4%), closed primarily in 4 (23.5%), and local flaps were used in 3 (27.3%). Postoperatively, the mean time to healing was 57.4 days ± 12.6. Complications included dehiscence (n = 1 [9.1%]), progression to cellulitis (n = 2 [18.2%]), osteomyelitis (n = 1 [9.1%]), and lower extremity amputation (n = 2 [18.2%]). Of the 6 patients alive at the time of healing, 5 (83.3%) were no longer taking narcotic medications. At an average follow-up of 26.4 months ± 34.1, 7 patients (63.6%) were deceased, with an average time to mortality of 4.8 months ± 6.7. Of the 4 remaining patients, 3 (75.0%) were ambulatory by their most recent follow-up visit. CONCLUSION: While the morbidity and mortality associated with calciphylaxis are substantial, surgical excision is effective in reducing pain and improving quality of life in patients with this end-stage disease. Wound care centers are uniquely equipped with a variety of medical and surgical specialists with experience in treating chronic wounds and thus facilitate an efficient multidisciplinary model.

Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction.

BACKGROUND: Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO. METHODS: Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status. RESULTS: A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups. CONCLUSION: This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.

Arterialized Vein Bypass Graft Recipient Vessel in Free Tissue Transfer Covering Diabetic Foot Ulcers Complicated by Critical Limb Ischemia.

ABSTRACT: Limb salvage options are limited in diabetic patients with critical limb ischemia. Soft tissue coverage remains technically demanding with limited recipient vessels for free tissue transfer. These factors make revascularization alone challenging. When open bypass revascularization is possible, venous bypass graft is optimal and functions as a recipient vessel for staged free tissue transfer.The authors present 2 cases using a combination approach of staged venous bypass graft revascularization followed by free tissue transfer with anastomosis to the venous bypass graft resulting in successful limb preservation.Free tissue transfer to a native vessel has limited application in severe peripheral vascular disease patients because early vascular compromise threatens flap survival. In both presented cases, venous bypass graft alone was insufficient to treat their nonhealing wounds, and preoperative angiogram revealed dismal options for free tissue transfer reconstruction. However, previous venous bypass graft provided an operable vessel for free tissue transfer anastomosis. The combination of venous bypass graft and free tissue transfer proved to be ideal for successful limb preservation by providing vascularized tissue to previously ischemic angiosomes, ensuring optimal wound healing capacity. Venous bypass graft is advantageous to native arterial grafts, and its combination with free tissue transfer likely increases graft patency and flap survival. We demonstrate that end-to-side anastomosis to a venous bypass graft is a viable option in these highly comorbid patients with favorable flap outcomes.

A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients.

Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n = 38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n = 16, 36% vs n = 1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n = 7, 33% vs Lisfranc: n = 7, 16%; p = .011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.

A comparative analysis of fasciocutaneous versus muscle free flaps in peripheral vascular disease patients.

OBJECTIVE: Chronic lower extremity (LE) wounds are common in patients with peripheral vascular disease (PVD). Free tissue transfer (FTT) provides healthy soft tissue for wound coverage and additional blood supply to promote wound healing. Given previous studies demonstrate increased complications in LE fasciocutaneous flaps, it was hypothesized that low vascular resistance in muscle flaps may be more advantageous for wound healing in PVD patients. Therefore, this study compared outcomes in PVD patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. METHODS: Retrospectively reviewed PVD patients undergoing FTT between 2011 and 2021. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included complications, flap success, post-reconstruction vascular interventions, limb salvage, and ambulatory status. RESULTS: One hundred thirteen patients with PVD were identified, of which 60.2% received fasciocutaneous (n = 68) and 39.8% received muscle flaps (n = 45). Forty-two patients (37.2%) underwent pre-flap endovascular interventions. Flap success rate was 98.2% (n = 111). Overall complication rate was 41.2% following fasciocutaneous flaps compared to 24.4% in muscle flaps (p = 0.067). Fasciocutaneous flaps had higher odds of ulceration requiring repeat angiogram within 1 year of reconstruction compared to muscle flaps (OR 3.4, 95% CI: 1.07-10.95, p = 0.047), and higher odds of requiring repeat angiogram overall (OR 3.4, 95% CI: 1.07-10.95, p = 0.047). No difference in requiring procedures in the operated limb within 1 year was observed (p = 0.155). At mean follow-up, there was no difference in limb salvage, ambulatory, and mortality rate between groups. CONCLUSION: This study demonstrates that fasciocutaneous flaps had higher postoperative complication rates and more commonly required repeat arteriograms following LE FTT reconstruction due to recurrent ulcerations, suggesting greater utility of muscle flaps for FTT reconstruction in PVD patients.

Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage.

OBJECTIVE: Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data. METHODS: Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates. RESULTS: A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01). CONCLUSIONS: In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.

Ensuring Quality Care in the COVID-19 Era: Applying the Donabedian Model to Tertiary Wound Care Center Practices.

The coronavirus disease of 2019 pandemic has disrupted health care, with its far-reaching effects seeping into chronic disease evaluation and treatment. Our tertiary wound care center was specially designed to deliver the highest quality care to wounded patients. Before the pandemic, we were able to ensure rapid treatment by means of validated protocols delivered by a colocalized multidisciplinary team within the hospital setting. The pandemic has disrupted our model's framework, and we have worked to adapt our workflow without sacrificing quality of care. Using the modified Donabedian model of quality assessment, we present an analysis of prepandemic and intrapandemic characteristics of our center. In this way, we hope other providers can use this framework for identifying evolving problems within their practice so that quality care can continue to be delivered to all patients.

From pay for performance to collaborative quality initiatives: quality care and implications for the limb salvage center.

Management of chronic wounds, specifically those of the lower extremity, varies considerably by geographic region. The consequences of low-quality care perpetuate poor outcomes and low value for patients and the health care system. The emergence of value-based health care has forced stakeholders to evaluate care from quality and cost perspectives. This review presents a replicable quality assessment model for limb salvage specialists to apply to their practices. This model will foster increased collaboration between caregivers across all disciplines in an effort to increase quality care assurances for patients with chronic wounds of the lower extremity. Current approaches to quality assessment in the management of such wounds are outlined, and areas for innovation, such as collaborative initiatives, are highlighted. Use of the Donabedian model to provide quality and value to patients undergoing treatment for chronic wounds at a tertiary limb salvage center is also described. A value-based care system can be comprehensively assessed using the Donabedian framework. A pay-for-performance approach has largely guided health care reform in the United States; however, the effects of this approach have been incongruent with its intent. Limb salvage centers work to rectify this imbalance and continually evaluate quality measures to improve care. Collaborative quality initiatives have resulted in improved outcomes and cost savings in multiple specialties, and multidisciplinary limb salvage centers may benefit from such infrastructure. Limb salvage specialists have an important role in determining whether health care quality improvements are internally or externally driven. Existing quality assessment tools are imperfect, and the consequences of low-quality care of chronic wounds can be devastating. Through collaboration across institutions and the use of validated quality assessment tools such as the Donabedian model, chronic wound specialists can be leaders in developing and implementing quality care measures.

Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths.

BACKGROUND: The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function. METHODS: A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05. RESULTS: BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation. CONCLUSIONS: The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.

Microsurgical vascular clamp injury causing arterial stenosis and subsequent free flap necrosis: A case report.

During microanastomosis, the recipient artery must be controlled both proximally and distally, so that the donor flap artery may be anastomosed. Bulldog vascular clamps are often used; however, these clamps may fail to occlude heavily calcified vessels characteristic of diabetes and end-stage renal disease. Alternative clamps may need to be utilized, with the attendant risk of vessel injury. Herein, we present a case of free flap necrosis secondary to vascular clamp-mediated periansastomotic stenosis of a calcified free flap recipient artery. In this case, a 74-year-old diabetic male underwent anterolateral thigh free flap reconstruction for a left medial foot wound. The recipient's dorsalis pedis artery was noted to be heavily calcified intraoperatively and Bulldog clamps were unable to gain proximal and distal control, requiring the use of small-angled DeBakey vascular clamps. Ischemic flap changes were noted on postoperative day four. Subsequent angiogram demonstrated severe stenosis at the perianastomotic sites of the dorsalis pedis where the DeBakey clamps were placed for control. The arterial lesions were treated with balloon angioplasty and the patient underwent multiple debridements and placement of a split-thickness skin graft over the wound. At the six-month follow up, the wound achieved complete healing with insetting of the skin graft. In certain cases, the use of DeBakey or Satinsky clamps for arterial control in microsurgery may predispose the artery to intimal injury, causing stenosis that should be recognized early so that arteriography may be performed expeditiously. In this study, alternative methods of vascular control are described.

Complications of Charcot Reconstruction in Patients With Peripheral Arterial Disease.

The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction.

A systematic review and meta-analysis of endovascular angiosomal revascularization in the setting of collateral vessels.

OBJECTIVE: Endovascular procedures for targeted treatment of lower extremity wounds can be subdivided as direct revascularization (DR), indirect revascularization (IR), and IR via collateral flow (IRc). Although previous systematic reviews assert superiority of DR when compared with IR, the role of collateral vessels in clinical outcomes remains to be defined. This systematic review and meta-analysis aims to define the usefulness of DR, IR, and IRc in treatment of lower extremity wounds with respect to (1) wound healing, (2) major amputation, (3) reintervention, and (4) all-cause mortality. METHODS: A meta-analysis was performed in accordance with PRISMA guidelines. Ovid MEDLINE was queried for records pertaining to the study question using appropriate Medical Subject Heading terms. Studies were limited to those using DR, IR, or IRc as a primary intervention and reporting information on at least one of the primary outcomes of interest. No limitation was placed on year of publication, country of origin, or study size. Studies were assessed for validity using the Newcastle-Ottawa Scale. Study characteristics and patient demographics were collected. Data representing the primary outcomes-wound healing, major amputation, reintervention, and all-cause mortality-were collected for time points ranging from one month to four years following intervention. A meta-analysis on sample size-weighted data assuming a random effects model was performed to calculate odds ratios (ORs) for the four primary outcomes at various time points. RESULTS: We identified 21 studies for a total of 4252 limbs (DR, 2231; IR, 1647; IRC, 270). Overall wound healing rates were significantly superior for DR (OR, 2.45; P = .001) and IRc (OR, 8.46; P < .00001) compared with, IR with no significant difference between DR and IRc (OR, 1.25; P = .23). The overall major amputation rates were significantly superior for DR (OR, 0.48; P < .00001) and IRc (OR, 0.44; P = .006) compared with IR, with DR exhibiting significantly improved rates compared with IRc (OR, 0.51; P = .01). The overall mortality rates showed no significant differences between DR (OR, 0.89; P = .37) and IRc (OR, 1.12; P = .78) compared with IR, with no significant difference between DR and IRc (OR, 0.54; P = .18). The overall reintervention rates showed no significant difference between DR and IR (OR, 1.05; P = .81), with no studies reporting reintervention outcomes for IRc. CONCLUSIONS: Both DR and IRc offer significantly improved wound healing rates and major amputation rates compared with IR when used to treat critical limb ischemia. Although DR should be the preferred method of revascularization, IRc can offer comparable outcomes when DR is not possible. This analysis was limited by a small sample size of IRc limbs, a predominance of retrospective studies, and variability in outcome definitions between studies.

Indirect Endovascular Revascularization via Collaterals: A New Classification to Predict Wound Healing and Limb Salvage.

BACKGROUND: In the setting of chronic limb ischemia, lower extremity (LE) wounds require revascularization of source arteries for wound healing and limb salvage. Direct revascularization of the source artery is preferred but cannot always be performed. Our objective was to analyze the influence of arterial-arterial connections on clinical outcomes after angiosome-directed endovascular revascularization. METHODS: Consecutive LE wounds in patients with isolated infra-popliteal disease revascularized endovascularly from 2012 to 2016 within a single center were retrospectively reviewed. Treatment was classified as direct revascularization (DR) if the source artery supplying the wound angiosome was treated, indirect revascularization via collaterals (IR-C) if the source artery angiosome was revascularized by another major artery via arterial connections, or indirect revascularization (IR) if direct revascularization of the source artery angiosome was not possible. Demographics, comorbidities, and patient outcomes were collected. RESULTS: Of 105 patients with 106 LE wounds, there were 35, 38, and 33 patients in the DR, IR-C, and IR groups, respectively. The mean age was 65.8 years old (standard deviation (SD) 11.9) with 81 males (77.1%) and 24 females (22.9%). Average follow-up was 21.0 months (SD 14.0). Overall wound healing rates were 80.0%, 92.1%, and 63.6% for DR, IR-C, and IR, respectively (P = 0.009). Significant differences were found between all 3 group comparisons, DR versus IR-C (P = 0.010), DR versus IR (P = 0.013), IR-C versus IR (P = 0.008). Overall major amputation-free survival was 85.7%, 89.5%, and 69.7% in DR, IR-C, and IR groups, respectively, with statistically significant differences between the IR-C and IR groups (P = 0.036). CONCLUSIONS: Treating diseased infra-popliteal arteries and improving blood flow via arterial-arterial connections as per the angiosome model improved wound healing and amputation-free survival in this cohort. Although DR is still the gold standard, revascularization using IR-C may give superior healing results even in highly comorbid patients. This offers an additional avenue for treatment, especially when DR is not possible.

Evaluation of Peripheral Perfusion in the Presence of Plantar Heel Ulcerations Status After Transmetatarsal Amputation With Achilles Tendon Lengthening.

The objective of this study is to evaluate peripheral perfusion in patients who developed plantar heel ulcerations status after transmetatarsal amputation and Achilles tendon lengthening. Peripheral perfusion was assessed via contrast angiography of the 3 crural vessels (anterior tibial, posterior tibial, and peroneal arteries), as well as intact heel blush and plantar arch. The secondary objective is to correlate the arterial flow to time to develop heel ulceration and incidence of minor and major lower-extremity amputation. Diagnostic angiography without intervention was performed on 40% of patients (4/10), and interventional angiography was performed on 60% of patients (6/10). In-line flow was present in 0% (0/10) of the peroneal arteries, 60% (6/10) of the anterior tibial arteries, and 70% (7/10) of the posterior tibial arteries. Heel angiographic contrast blush was present in 60% (6/10), and intact plantar arch was present in 60% (6/10). Patients developed heel ulcerations at a mean time of 7.6 months (range 0.7 to 41.2) postoperatively. The incidence of major lower-extremity amputation was 30% (3/10), with a mean time of 5.2 months (range 3.5 to 8.3) from time of heel wound development. No amputation occurred in 6 patients (60%). Among them, intact anterior tibial inline arterial flow was present in 3, intact posterior tibial inline arterial flow was present in 6, and heel blush was present in 5. Our results demonstrate that an open calcaneal branch of the posterior tibial artery is sufficient to heal plantar heel ulcerations to potentially increase rates of limb salvage.

Peripheral Vascular Disease Diagnostic Related Outcomes in Diabetic Charcot Reconstruction.

Postreconstructive outcomes were compared in diabetic patients with Charcot neuroarthropathy (CN) who had peripheral arterial disease (PAD) diagnosed with angiography versus patients who were diagnosed clinically. A retrospective review was performed of patients with diabetic CN requiring reconstruction secondary to ulceration and/or acute infection. Of the 284 patients in the CN osseous reconstruction cohort, after accounting for exclusion criteria, 59 (20.8%) patients with PAD were included in the analyses. Forty (67.8%) of these 59 patients were diagnosed with PAD clinically and 19 (32.2%) were diagnosed with the use of angiography. Bivariate analysis was used to compare outcomes between those diagnosed with PAD via angiography versus those diagnosed clinically for the following postreconstruction outcomes: wound healing, delayed healing, surgical site infection, pin tract infection, osteomyelitis, dehiscence, transfer ulcer, new site of Charcot collapse, contralateral Charcot event, nonunion, major lower extremity amputation, and return to ambulation. Bivariate analysis found return to ambulation postreconstruction (p = .0054) to be the only statistically significant factor. There was a trend toward significance for major lower extremity amputation, with higher rates of amputation in the clinically diagnosed PAD arm. Return to ambulation indicates improved functional outcomes. The main goal of limb salvage should be focused on improving the patient's functional performance. With significantly faster rates of return to ambulation and a trend toward decreased rates of major amputation, angiography was found to be a better assessor of PAD than clinical evaluations.

Outcomes of Split-thickness Skin Grafting for Foot and Ankle Wounds in Patients With Peripheral Arterial Disease.

INTRODUCTION: Tissue ischemia resulting from arterial insufficiency is a major factor affecting lower extremity wound healing in patients with peripheral arterial disease (PAD). Accelerated wound closure with split-thickness skin grafting (STSG) provides a durable barrier to infection and can prevent limb loss. Published STSG outcomes data are minimal in the post endovascular intervention population. OBJECTIVE: In this study, the authors examine factors predictive of STSG healing in patients with PAD following vascular intervention, including the effect of non-inline flow via arterial-arterial and non-arterial collateralization. MATERIALS AND METHODS: Patients with PAD and wounds of the foot and ankle who underwent STSG between January 2014 and December 2016 were retrospectively reviewed. All patients received angiographic evaluation and endovascular or open revascularization where necessary. Effects of extremity revascularizations, STSG percent take, and amputation rate were evaluated. RESULTS: Thirty-five patients with 47 wounds underwent STSG. There were 21 men and 14 women with a mean age of 64 ± 13 years. Revascularization was required in 23 patients (25 extremities) before STSG, with balloon angioplasty for tibial artery lesions as the most common revascularization. Patent pedal arch was present in 8 patients; 35 patients had an absent or incomplete pedal arch. Patients with a fully patent pedal arch healed at a significantly higher rate than those with an absent or incomplete pedal arch at 1 month (62.5% vs. 17.1%, P ⟨ .05). At 90-day follow-up, 9 of 35 (25.7%) patients with 9 of 47 (19.1%) wounds were lost to follow-up, leaving 18 of 38 (47.37%) wounds healed and 20 (52.63%) still open. Ultimately, 36 of 47 (76.60%) wounds healed and 6 major amputations in 6 patients were required at a mean 502 ± 342 days follow-up. CONCLUSIONS: These results suggest the importance of arterial-arterial connections such as the pedal arch to the healing potential of foot and ankle wounds after STSG in this high-risk patient population.