A novel low-density lipoprotein/fibrinogen apheresis method for chronic limb-threatening ischemia in patients with poor options for revascularization: A multicenter, single-arm clinical trial.

INTRODUCTION: Low-density lipoprotein (LDL) apheresis is a treatment option for patients with unhealed chronic limb-threatening ischemia (CLTI) after revascularization. The newly developed AS-25 is a direct hemoperfusion-type apheresis device that differs from conventional LDL apheresis therapy and is designed to specifically adsorb both LDL-C and fibrinogen. We evaluate the efficacy and safety of AS-25. METHODS: This study included 61 patients whose ulcers failed to heal after revascularization or were ineligible for revascularization. Of these, 50 were undergoing hemodialysis. The primary endpoint was the healing rate of a target lesion of interest (ulcer), using historical data as control. RESULTS: The ulcer healing rate of 45.9% was significantly higher than the historical data. No significant safety concerns were observed. CONCLUSIONS: AS-25 was effective in healing ulcers and preventing major amputation even in CLTI refractory patients on hemodialysis, thus showing potential clinical applicability and high significance. CLINICAL TRIAL REGISTRATION: UMIN study ID UMIN000020336.

Assessment of 3-Year Patency after Endoluminal versus Surgical Bypass Therapy for Complex Femoropopliteal Artery Disease.

PURPOSE: To compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass for complex femoropopliteal (FP) arterial lesions. MATERIALS AND METHODS: In this retrospective multicenter study, 530 patients with symptomatic peripheral artery disease (Rutherford classification 1-3, 66.0%; 4-6, 34.0%) who underwent either endoluminal bypass with Viabahn stent grafts (n = 276) or surgical bypass (n = 254) (with saphenous vein grafts, 74.4%; prosthetic grafts, 25.6%) for FP arterial lesions between 2010 and 2018 were analyzed. The propensity score-matched analysis was performed to compare the 3-year clinical outcomes of endoluminal bypass with those of surgical bypass. The primary end point was primary patency (freedom from restenosis). The secondary end points were secondary patency, freedom from target lesion revascularization (TLR), limb salvage, and overall survival. The interaction effect of baseline characteristics on the association of the revascularization strategy with the risk of restenosis was analyzed using the Poisson mixed-effect model. RESULTS: The propensity score-matched analysis extracted 107 pairs. After propensity score matching, the primary patency rate at 1, 2, and 3 years was 84.5%, 75.1%, and 70.9%, respectively, for the endoluminal bypass group versus 78.6%, 73.3%, and 72.0%, respectively, for the surgical bypass group (P = .65). There was no significant difference in secondary patency, freedom from TLR, limb salvage, and overall survival (all P > .05). The subsequent interaction analysis revealed that the involvement of popliteal lesions, small distal reference vessel diameters, and long lesions favored surgical bypass over endoluminal bypass because of improved primary patency (all P for interaction < .05). CONCLUSIONS: The 3-year clinical outcomes after endoluminal bypass or surgical bypass for FP arterial lesions were similar.

Influence of Peripheral Arterial Disease on Wound Healing in Heel Pressure Ulcers.

BACKGROUND: There are cases of heel pressure ulcer with peripheral arterial disease (PAD). The influence of ischemia on wound healing was investigated. METHODS: We retrospectively studied 253 patients with heel ulcers treated between January 2003 and March 2018. The patients were classified into PAD and non-PAD groups. The wound healing rate, wound healing time and the factors that influenced wound healing were examined. RESULTS: There were 186 patients with PAD (73.5%). There were 41 (22.0%) and 35 (52.2%) wound healing cases with PAD and non-PAD, respectively (P < 0.001). In the non-PAD group, the deeper the ulcer, the lower the wound healing rate. However, in the PAD group, the increase in blood flow owing to revascularization affected the wound healing rate. The wound healing rate in the endovascular therapy (EVT) and bypass groups were 26.7% and 65.0%, respectively (P = 0.003). The wound healing time was 128 (interquartile range [IQR] 88－196) and 79 (IQR 35.5－187) days, with PAD and non-PAD, respectively (P = 0.0268). The wound healing time in the PAD group was 128 (IQR 93－174.5) days with bypass and 155.5 (IQR 86－237.5) days with EVT (P = 0.459). CONCLUSIONS: Heel pressure ulcers with PAD are difficult to treat. The wound healing rate was lower in the PAD than in the non-PAD group and the wound healing time also tended to be long. Successful revascularization is important for wound healing and bypass surgery had a shorter wound healing time and a higher wound healing rate than EVT.

Health Related Quality of Life Over Time After Revascularisation in Patients With Chronic Limb Threatening Ischaemia.

OBJECTIVE: Chronic limb threatening ischaemia (CLTI) decreases life expectancy and impairs health related quality of life (HR-QOL). Revascularisation is needed to relieve ischaemia and salvage limbs. Although a major goal of CLTI treatment is maintaining QOL, little information is available about changes of HR-QOL over time after revascularisation. HR-QOL with survival after revascularisation for CLTI was assessed. METHODS: The clinical database of the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia (SPINACH), a prospective multicentre observational study, was analysed. Outcome measures were disease specific QOL per the Vascular Quality of Life (VascuQOL) questionnaire and the Short Form (SF) 36 evaluated generic QOL, which were assessed at baseline and three, 12, 24, and 36 months. The outcome measure was change of QOL from baseline. The minimally important difference (half a standard deviation from baseline) was used as the cut off point for improved, worsened, and unchanged QOL. RESULTS: Overall QOL was improved in 61% of patients for the VascuQOL and approximately 40% for the SF-36 component summaries at three months. However, these proportion gradually decreased to 21% - 31% at three years. In contrast, the proportion of deceased patients gradually increased over the three year follow up. Multivariable analysis revealed that pre-operative non-ambulatory status was inversely associated with improved QOL for the three month VascuQOL and SF-36 mental component summary, and surgical reconstruction was positively associated with these measurements. Advanced age and renal failure were inversely associated with improved QOL for the SF-36 mental component summary and VascuQOL at one to three years. CONCLUSION: Revascularisation improved QOL. However, patients with non-ambulatory status exhibited a negative association with improved QOL at three months, and advanced age and renal failure limited benefits one to three years after revascularisation. Accumulating QOL data will be essential for post-revascularisation QOL estimation. Pre-operative assessment, including estimated QOL, is important in shared decision making for patient oriented outcomes in the treatment of CLTI patients.

Tension-Free Management of Surgical Wound in Paramalleolar Bypass.

Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency. Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis. Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months. Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.

Comparison of Clinical Outcomes between Endovascular Therapy with Self-Expandable Nitinol Stent and Femoral-Popliteal Bypass for Trans-Atlantic Inter-Society Consensus II C and D Femoropopliteal Lesions.

BACKGROUND: Femoral-popliteal (F-P) bypass is the standard treatment for lower extremity peripheral artery disease with severe femoropopliteal (FP) artery lesions. However, in clinical settings, these patients are treated with endovascular therapy (EVT) because of frailty and difficulties with general anesthesia. We compared the clinical outcomes of F-P bypass and EVT for severe FP artery lesions and investigated the types of patients for whom EVT would be as appropriate as F-P bypass. METHODS: This multicenter, retrospective study included 452 Trans-Atlantic Inter-Society Consensus (TASC) II C and D FP artery lesions in 352 patients. A total of 350 lesions in 260 patients (74 ± 9 years, 66% male, 60% claudication) were treated with EVT with nitinol self-expandable stents, and 102 lesions in 92 patients (71 ± 9 years, 75% male, 40% claudication) were treated with F-P bypass. The primary outcome measure was primary patency, and the influence of baseline characteristics on its association with the treatment strategy (EVT versus F-P bypass) was assessed using a Cox proportional hazards regression model. RESULTS: Kaplan-Meier analysis indicated that the 3-year primary patency rate was significantly lower for EVT than F-P bypass (60% vs. 74%, P < 0.01). The body mass index (BMI) and C-reactive protein (CRP) levels significantly interacted with the treatment strategy for restenosis (P < 0.05). The adjusted hazard ratios of EVT versus F-P bypass for restenosis were 0.77 (P = 0.46) in cases with a low BMI (≤18 kg/m2) or an elevated CRP level (≥1 mg/dL) and 3.35 (P < 0.01) in other cases. The 3-year primary patency rate was not significantly different between the EVT and F-P bypass groups in patients with BMI ≤ 18 kg/m2 or CRP ≥ 1 mg/dL (57% vs. 45%, P = 0.84). CONCLUSIONS: In TASC II C and D lesions, EVT appears to yield patency comparable to that of F-P bypass in patients with a low BMI or an elevated CRP level, but lower patency in other patients.

Outcomes of Popliteal-To-Distal Bypass Combined with Femoropopliteal Artery Endovascular Treatment for Critical Limb Ischemia.

Objective: The aim of this study was to evaluate outcomes of combined popliteal-to-distal bypass and endovascular treatment (EVT) for femoropopliteal lesions in patients with critical limb ischemia (CLI). Patients and Methods: We reviewed data of 14 CLI patients who were treated by popliteal-to-distal bypass combined with femoropopliteal EVT. The femoropopliteal lesions included 3 TASC II-A, 8 TASC II-B, and 3TASC II-C but no TASC II-D, and balloon dilatation was performed in 9 cases and a stent was placed in 5 cases. The saphenous vein graft was used in all bypasses, and the target arteries were the dorsalis pedis artery in 12 cases and the posterior tibial artery in 2 cases. Results: At 12 and 24 months, primary patency rates were both 79%, primary assisted and secondary patency rates were both 93%, limb salvage rates were both 93%, and survival rates were 92% and 84%, respectively. Restenosis after femoropopliteal EVT occurred in 2 cases, and both were successfully revised by additional endovascular balloon dilatation. Conclusion: Combined popliteal-to-distal bypass and femoropopliteal EVT might be a useful therapeutic option for appropriately selected CLI patients. Intensive follow-up for endovascular treated lesions and vein graft is mandatory.

Impact of infrapopliteal endovascular treatment on the outcome of subsequent ipsilateral distal bypass for critical limb ischemia.

BACKGROUND: We retrospectively reviewed the outcomes of distal bypass for critical limb ischemia and investigated the impact on outcomes of prior unsuccessful ipsilateral infrapopliteal endovascular treatment (EVT). METHODS: Between January 2005 and December 2014, we performed 142 infrainguinal bypasses for critical limb ischemia with ischemic gangrene (Rutherford classes V or VI), including 80 distal bypasses in 74 patients (male 54, female 20, median age 68.4 years, range 51-81 years). All distal bypasses used an autologous saphenous vein graft. Surgical outcomes were compared between 37 distal bypasses without prior infrapopliteal EVT (NEVT group) and 43 distal bypasses after unsuccessful infrapopliteal EVT (PEVT group). Infrapopliteal EVT was performed with balloon dilatation without stenting in all cases. RESULTS: There were no significant differences in preoperative conditions or risk factors between the NEVT and PEVT groups, except for the era of bypass surgery and dependence on hemodialysis. The 3-year primary and secondary patencies were 69% and 72% in the NEVT group and 78% and 80% in the PEVT group (P=0.86, P=0.79). The 3-year limb salvage rates were 81% in the NEVT group and 82% in the PEVT group (P=0.52), and the 3-year amputation-free survival rates were 56% and 57% in the respective groups (P=0.32). Standard errors of the mean for all Kaplan-Meier curves were <10% within 3 years follow-up. CONCLUSIONS: The clinical outcomes of distal bypass without prior infrapopliteal EVT were not superior to those of distal bypass after unsuccessful ipsilateral infrapopliteal EVT. Therefore, unsuccessful infrapopliteal EVT does not have a negative impact on the outcome of subsequent ipsilateral distal bypass in patients with critical limb ischemia.

Comparison of Clinical Outcomes after Surgical and Endovascular Revascularization in Hemodialysis Patients with Critical Limb Ischemia.

AIM: The treatment strategy for hemodialysis (HD) patients with critical limb ischemia (CLI) has been clinically debatable. Here we compared clinical outcomes after bypass surgery (BSX) and after endovascular therapy (EVT) using propensity score matching. METHODS: A retrospective multicenter database of 246 (68 BSX and 178 EVT) consecutive HD patients with CLI (79% with tissue loss) who underwent infrainguinal revascularization from 2007 to 2009 was used to compare clinical outcomes, including overall survival (OS), major amputation (MA), major adverse limb event (MALE: repeat EVT, surgical reconstruction, or MA), and MALE-free survival after BSX vs. EVT using propensity score matching. RESULTS: The median (interquartile range) follow-up duration after revascularization was 21 (8-33) months. The analysis of the 63 propensity score-matched pairs revealed no significant difference in OS (53% vs. 52%, P=0.96), MA (25% vs. 14%, P=0.71), MALE (42% vs. 58%, P=0.63), and MALE-free survival (33% vs. 11%, P=0.37) at 3 year after BSX vs. EVT. CONCLUSIONS: In HD patients with CLI who underwent infrainguinal revascularization, OS, MA, MALE, and MALE-free survival rates were not significantly different after EVT vs. BSX. The less invasive EVT should be considered as the first-choice therapeutic strategy for HD patients with CLI.

3-Year Outcomes of the OLIVE Registry, a Prospective Multicenter Study of Patients With Critical Limb Ischemia: A Prospective, Multi-Center, Three-Year Follow-Up Study on Endovascular Treatment for Infra-Inguinal Vessel in Patients With Critical Limb Ischemia.

OBJECTIVES: This study sought to investigate the 3-year follow-up results of OLIVE registry patients. BACKGROUND: Although favorable 12-month clinical outcomes after endovascular therapy (EVT) in OLIVE registry patients with critical limb ischemia (CLI) from infrainguinal disease have been reported, long-term results after EVT remain unknown. METHODS: This was a prospective multicenter registry study that consecutively enrolled patients who received infrainguinal EVT for CLI. The primary outcome was 3-year amputation-free survival (AFS), whereas secondary outcome measures were 3-year freedom from major adverse limb events (MALE), wound-free survival, and wound recurrence rate. Prognostic predictors for each outcome were also elucidated by Cox proportional hazard regression analysis or the log-rank test. RESULTS: The completion rate of 3-year follow-up was 95%. Three-year AFS, freedom from MALE, and wound-free survival rates were 55.2%, 84.0%, and 49.6%, respectively. Wound recurrence out to 3 years was 43.9%. After multivariable analysis, age (hazard ratio [HR]: 1.43, p = 0.001), body mass index ≤18.5 (HR: 2.17, p = 0.001), dialysis (HR: 2.91, p < 0.001), and Rutherford 6 (HR: 1.64, p = 0.047) were identified as predictors of 3-year major amputation or death. Statin use (HR: 0.28, p = 0.02), Rutherford 6 (HR: 2.40, p = 0.02), straight-line flow to the foot (HR: 0.27, p = 0.001), and heart failure (HR: 1.96, p = 0.04) were identified as 3-year MALE predictors. Finally, CLI due to isolated below-the-knee lesion was a wound recurrence predictor (HR: 4.28, p ≤ 0.001). Three-year survival, freedom from major amputation, and reintervention rates were 63.0%, 87.9%, and 43.2%. CONCLUSIONS: In CLI patients with infrainguinal lesions, 3-year clinical results of EVT were reasonable despite high reintervention and moderate ulcer recurrence rate. (A Prospective, Multi-Center, Three-Year Follow-Up Study on Endovascular Treatment for Infra-Inguinal Vessel in Patients With Critical Limb Ischemia [OLIVE 3-Year Follow-Up Study]; UMIN000014759).

Predictors of 2-Year Mortality and Risk Stratification After Surgical or Endovascular Revascularization of Infrainguinal Artery Disease in Hemodialysis Patients With Critical Limb Ischemia.

PURPOSE: To examine the 2-year mortality in hemodialysis (HD) patients with critical limb ischemia (CLI) and determine predictors that may aid in the selection of a revascularization strategy [bypass surgery or endovascular therapy (EVT)] according to current guidelines. METHODS: From 2007 to 2009, 246 consecutive CLI patients (mean age 69±10 years; 170 men) on HD underwent revascularization for de novo infrainguinal lesions (178 EVT and 68 bypass grafting). The majority of the patients had diabetes (170, 69%) and tissue loss (194, 79%); nearly half (111, 45%) were nonambulatory. Overall survival after revascularization was estimated by Kaplan-Meier analysis. Predictors for 2-year mortality after revascularization were determined using a Cox proportional hazards model; results are given as the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Overall survival rate was 77% at 1 year and 66% at 2 years. Predictors of 2-year mortality after revascularization were age >75 years (HR 1.82, 95% CI 1.14 to 2.91, p=0.012), albumin <3 g/dL (HR 2.31, 95% CI 1.39 to 3.84, p=0.001), and ejection fraction <50% (HR 1.73, 95% CI 1.06 to 2.83, p=0.027). Patients with more predictors had a higher incidence of death within 2 years after revascularization. CONCLUSION: Advanced age, low albumin level, and low ejection fraction were independently associated with 2-year mortality after revascularization in HD patients with CLI. Risk stratification by these factors would be useful for deciding on a revascularization strategy.

Postprocedural Skin Perfusion Pressure Correlates With Clinical Outcomes 1 Year After Endovascular Therapy for Patients With Critical Limb Ischemia.

BACKGROUND: Although skin perfusion pressure (SPP) is widely used clinically to predict probability of wound healing, correlation between clinical outcomes and SPP has not been systematically studied. METHODS: This subanalysis of the prospective multicenter OLIVE registry of patients who received infrainguinal endovascular therapy (EVT) for critical limb ischemia (CLI) assessed the association between clinical outcomes and postoperative SPP in 211 consecutive patients. Logistic regression analysis was performed, with amputation-free survival (AFS), modified major adverse limb events (MALEs), and complete wound healing as dependent variables and postprocedural SPP as independent variable. RESULT: Pre- and postprocedural SPP was 28 ± 11 and 46 ± 18 mm Hg, respectively. In logistic regression analysis, postprocedural SPP correlated with 1-year AFS (P = .018), modified MALEs (P < .001), and wound healing (P = .022). CONCLUSION: Postprocedural SPP correlates with clinical outcomes after EVT for patients with CLI.

Traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery.

We describe a rare case of traumatic disruption of saphenous vein graft bypassed to the dorsalis pedis artery. The vein graft was disrupted at the level of ankle joint by blunt trauma and symptoms of acute foot ischemia were recognized. The injured vein graft was reconstructed with cephalic vein graft interposition. He has been free from any events of foot ischemia at 10 months follow-up with patent vein graft to the dorsalis pedis artery.

Endovascular treatment for infrainguinal vessels in patients with critical limb ischemia: OLIVE registry, a prospective, multicenter study in Japan with 12-month follow-up.

BACKGROUND: Recent technical advances have made endovascular treatment (EVT) an alternative first-line treatment for critical limb ischemia. METHODS AND RESULTS: A prospective multicenter study was conducted to evaluate the clinical outcomes of 314 Japanese critical limb ischemia patients (mean age, 73±10 years) with infrainguinal arterial lesions who underwent EVT. Patients were enrolled from December 2009 to July 2011 and were followed-up for 12 months. The primary end point was amputation-free survival (AFS) at 12 months. Secondary end points were anatomic, clinical, and hemodynamic measures, including 12-month freedom from major adverse limb events. The 12-month AFS rate was 74%, with body mass index <18.5 (hazard ratio [HR], 2.22; P=0.008), heart failure (HR, 1.73; P=0.04), and wound infection (HR, 1.89; P=0.03) associated with a poor prognosis for AFS. The 12-month major adverse limb event-free rate was 88%, with hemodialysis (HR, 1.98; P=0.005), heart failure (HR, 1.69; P=0.02), and Rutherford classification 6 (HR, 2.25; P=0.002) associated with a poor prognosis for major adverse limb events. The median time for wound healing was 97 days, with body mass index <18.5 (HR, 0.54; P=0.03) and wound infection (HR, 0.60; P=0.04) being significant risk factors for unhealed wounds after EVT. At 12 months, 34% had undergone reintervention (bypass surgery, 2.6%; repeat EVT, 31.7%), and 73% were major adverse event-free. CONCLUSIONS: The high reintervention rate notwithstanding, EVT was an effective treatment for Japanese critical limb ischemia patients with infrainguinal disease, with satisfactory AFS and major adverse limb event-free rates. The results of this study will be helpful for the future evaluation of critical limb ischemia therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.umin.ac.jp/ctr. Unique identifier: UMIN000002830.

Popliteal pseudoaneurysm caused by stent fracture.

Stent fracture with pseudoaneurysm formation in the femoropopliteal artery has uncommonly been reported. We present the case of a 72-year-old man with a fracture of self-expanding nitinol stent and a pseudoaneurysm formation in the suprageniculate popliteal artery. The popliteal artery was successfully reconstructed with a small saphenous vein graft interposition.

A modified transmetatarsal amputation.

The incidence of the diabetic foot is increasing worldwide. Because evidence has shown that transmetatarsal amputation is associated with fewer failures in amputations of the diabetic foot with or without peripheral arterial disease, improving its management and surgical technique is a mission for the surgeon. Conventional transmetatarsal amputation has held firm, however, for more than 150 years. With a new concept for the transmetatarsal amputation method aimed at a better outcome, we propose a modified procedure for preserving the soft tissue between the metatarsal bones (the vasculature complex with the muscles, periostea, and vessels) and applying it to the distal bone stumps. The purpose of this method is to secure a functional foot by preserving the longitudinal arch. The new method was applied to 11 patients with diabetes mellitus or peripheral arterial disease, or both. All wounds closed successfully. Of the 11 patients, 8 were still alive with no complications. Of these 8 patients, 6 were able to ambulate with a custom-made shoe and 2 used a wheelchair, just as preoperatively. Of the 3 patients who died, 1 died a natural death, 1 died of sepsis, and 1 of cerebral infarction. We believe that the modified transmetatarsal amputation that we have described in this report is a potential breakthrough in the care of patients with forefoot gangrene and may gain acceptance over time.

Total management of diabetic foot ulcerations--Kobe classification as a new classification of diabetic foot wounds.

Treatment must be conducted after proper assessment of diabetic foot wounds. This implies appropriate foot care and the use of proper footwear from the perspectives of prophylaxis and walking. Diabetic foot wounds have some wound impairment factors, including peripheral neuropathy (PN), peripheral arterial disease (PAD), and infection; such wounds comprise combinations of these lesions. An additional goal besides wound healing is gait salvage. Here, we propose a simple new four-level classification of diabetic foot ulcerations, which we have termed the Kobe classification, in order to assess the wounds more easily and treat them systematically; the classification is as follows: Type I, mainly PN; Type II, mainly PAD; Type III, mainly infection; Type IV, PN+PAD+infection.

Importance of skin perfusion pressure in treatment of critical limb ischemia.

UNLABELLED:  The authors studied whether skin perfusion pressure (SPP) measurements can be used to accurately predict wound healing in critical limb ischemia (CLI) and to select peripheral arterial reconstructive procedures. METHODS: Forty-seven patients (33 men and 14 women, age 36-83 years) with 69 ischemic limbs with foot ulcers or gangrene were studied retrospectively. Skin perfusion pressure was compared to the treatment outcomes (ulcers healed and ulcers that failed to heal). As a diagnostic test for CLI, the sensitivity, specificity, and the positive and the negative predictive values (PPV, NPV) of SPP measurement were calculated; the data was then analyzed by the receiver operation characteristic (ROC) curve. RESULTS: According to the ROC curve, the best SPP measurement performance was at 35 mmHg. CONCLUSION: Wound healing at the appropriate amputation level must be predicted to minimize invasive debridement. Skin perfusion pressure measurement is useful for predicting wound healing in the presence of CLI. Skin perfusion pressure ≥ 35 mmHg is requisite for wound healing; at SPP <35 mmHg, peripheral arterial reconstruction is necessary before debridement.

Lymphatic cardiac tamponade after open-heart surgery with liver dysfunction.

A 46-year-old female with alcoholic liver dysfunction was admitted for mitral regurgitation due to infective endocarditis. She underwent mitral valvuloplasty and resection of the vegetation without complication. After removal of the chest tube, late cardiac tamponade occurred and subsequently recurred. On the 64th day after mitral valvuloplasty, we performed redo median sternotomy with small laparotomy trying to reveal and repair injured lymphatic vessels in the pericardial space and successfully cured the leakage of lymph. The post reoperative course was uneventful and the patient was discharged 20 days after reoperation. We review a rare complication of recurrent cardiac tamponade of lymphatic leakage associated with liver dysfunction.