Transcatheter Arterialization of Deep Veins in Chronic Limb-Threatening Ischemia.

BACKGROUND: Approximately 20% of patients with chronic limb-threatening ischemia have no revascularization options, leading to above-ankle amputation. Transcatheter arterialization of the deep veins is a percutaneous approach that creates an artery-to-vein connection for delivery of oxygenated blood by means of the venous system to the ischemic foot to prevent amputation. METHODS: We conducted a prospective, single-group, multicenter study to evaluate the effect of transcatheter arterialization of the deep veins in patients with nonhealing ulcers and no surgical or endovascular revascularization treatment options. The composite primary end point was amputation-free survival (defined as freedom from above-ankle amputation or death from any cause) at 6 months, as compared with a performance goal of 54%. Secondary end points included limb salvage, wound healing, and technical success of the procedure. RESULTS: We enrolled 105 patients who had chronic limb-threatening ischemia and were of a median age of 70 years (interquartile range, 38 to 89). Of the patients enrolled, 33 (31.4%) were women and 45 (42.8%) were Black, Hispanic, or Latino. Transcatheter arterialization of the deep veins was performed successfully in 104 patients (99.0%). At 6 months, 66.1% of the patients had amputation-free survival. According to Bayesian analysis, the posterior probability that amputation-free survival at 6 months exceeded a performance goal of 54% was 0.993, which exceeded the prespecified threshold of 0.977. Limb salvage (avoidance of above-ankle amputation) was attained in 67 patients (76.0% by Kaplan-Meier analysis). Wounds were completely healed in 16 of 63 patients (25%) and were in the process of healing in 32 of 63 patients (51%). No unanticipated device-related adverse events were reported. CONCLUSIONS: We found that transcatheter arterialization of the deep veins was safe and could be performed successfully in patients with chronic limb-threatening ischemia and no conventional surgical or endovascular revascularization treatment options. (Funded by LimFlow; PROMISE II study ClinicalTrials.gov number, NCT03970538.).

Controversies in the pathophysiology of leg ulcers in sickle cell disease.

Patients with sickle cell disease (SCD) often experience painful vaso-occlusive crises and chronic haemolytic anaemia, as well as various acute and chronic complications, such as leg ulcers. Leg ulcers are characterized by their unpredictability, debilitating pain and prolonged healing process. The pathophysiology of SCD leg ulcers is not well defined. Known risk factors include male gender, poor social conditions, malnutrition and a lack of compression therapy when oedema occurs. Leg ulcers typically start with spontaneous pain, followed by induration, hyperpigmentation, blister formation and destruction of the epidermis. SCD is characterized by chronic haemolysis, increased oxidative stress and decreased nitric oxide bioavailability, which promote ischaemia and inflammation and consequently impair vascular function in the skin. This cutaneous vasculopathy, coupled with venostasis around the ankle, creates an ideal environment for local vaso-occlusive crises, which can result in the development of leg ulcers that resemble arterial ulcers. Following the development of the ulcer, healing is hindered as a result of factors commonly observed in venous ulceration, including venous insufficiency, oedema and impaired angiogenesis. All of these factors are modulated by genetic factors. However, our current understanding of these genetic factors remains limited and does not yet enable us to accurately predict ulceration susceptibility.

Impact of genotype on multi-organ iron and complications in patients with non-transfusion-dependent ß-thalassemia intermedia.

We evaluated the impact of the genotype on clinical and hematochemical features, hepatic and cardiac iron levels, and endocrine, hepatic, and cardiovascular complications in non-transfusion-dependent (NTD) ß-thalassemia intermedia (TI) patients. Sixty patients (39.09 ± 11.11 years, 29 females) consecutively enrolled in the Myocardial Iron Overload in Thalassemia project underwent Magnetic Resonance Imaging to quantify iron overload, biventricular function parameters, and atrial areas and to detect replacement myocardial fibrosis. Three groups of patients were identified: homozygous ß+ (N = 18), heterozygous ß0ß+ (N = 22), and homozygous ß0 (N = 20). The groups were homogeneous for sex, age, splenectomy, hematochemical parameters, chelation therapy, and iron levels. The homozygous ß° genotype was associated with significantly higher biventricular end-diastolic and end-systolic volume indexes and bi-atrial area indexes. No difference was detected in biventricular ejection fractions or myocardial fibrosis. Extramedullary hematopoiesis and leg ulcers were significantly more frequent in the homozygous ß° group compared to the homozygous ß+ group. No association was detected between genotype and liver cirrhosis, hypogonadism, hypothyroidism, osteoporosis, heart failure, arrhythmias, and pulmonary hypertension. Heart remodelling related to a high cardiac output state cardiomyopathy, extramedullary hematopoiesis, and leg ulcers were more pronounced in patients with the homozygous ß° genotype compared to the other genotypes analyzed. The knowledge of the genotype can assist in the clinical management of NTD ß-TI patients.

Leg ulcers are indicators of systemic dysfunction in individuals with sickle cell disease.

Leg ulcers in individuals living with Sickle Cell Disease are evidence of systemic dysfunction. Data from a U.S. study link leg ulcers to wider pulse pressure and markers of chronic hemolysis, inflammation, renal, and liver dysfunction.

Prevalence and characteristics of pain in patients with lower-extremity ulcers-A cross-sectional study.

The study aimed to investigate the prevalence and characteristics of pain in different ulcer types and to identify factors associated with pain experience in patients with lower-extremity ulcers. A cross-sectional single-centre study was performed, including 130 newly referred outpatients with lower-extremity ulcers. Pain intensity was measured with a visual analog scale (VAS) and pain characteristics with the short form mcgill pain questionnaire-2 (SF-MPQ-2). The mean pain intensity was 29.5 (SD 31.8) at rest and 35.5 (SD 34.1) during movement (0-100 VAS). 61.5% of the patients experienced pain (VAS > 0) at rest and 70.8% during movement. Moderate to severe pain at rest was seen in 39.2% and in 43.8% of patients during movement. The mean total score on SF-MPQ-2 (range 0-220) was 35.9 (SD 32.6). Most of the patients described pain as intermittent (mean 11.8 SD 13.9). Analgesics were prescribed for 78% of the patients. Ulcer type (i.e., arterial, immunological, pressure and venous) and age were associated with pain severity, and women had a significantly lower well-being score than men. Prevalence of pain in patients with lower-extremity ulcers was high across different ulcer aetiologies. Pain intensity and quality must be assessed to obtain adequate pain management.

Noncompliance with Guidelines on the Use of Ultrasound and Pentoxifylline in the Treatment of Venous Ulcers in a Rural Health Care System.

Guidelines based on randomized controlled data recommend patients with newly diagnosed venous leg ulcers (VLUs) to undergo venous reflux duplex ultrasound (US) and be considered for treatment with pentoxifylline to accelerate ulcer healing. A retrospective review was conducted of 2,061 patients with VLU diagnosed between 2011 and 2020 in a rural health care system to identify factors associated with increased or decreased likelihood of being prescribed venous reflux duplex US and pentoxifylline. Venous reflux duplex US (16%) and pentoxifylline (0.7%) were prescribed infrequently. Evaluation by a vascular specialist was associated with a significantly increased frequency of undergoing venous reflux duplex US (5%-38%). Seeing a wound care specialist was associated with an increased frequency of being prescribed pentoxifylline (0.7%-1.4%). Increased referral to specialists and/or referring clinician education on guideline-based care may be of benefit to patients with VLUs. Pentoxifylline seems underused, even by specialists. Further study is needed to confirm these findings and determine whether they are generalizable.

Identifying Key Drivers in the Pathogenesis of Martorell Hypertensive Ischaemic Leg Ulcer: A Comparative Analysis with Chronic Venous Leg Ulcer.

Martorell hypertensive ischaemic leg ulcer (Martorell HYTILU) is a rare but significant cause of distal leg ulcers. Although hypertension and diabetes are known factors in its development, the precise pathogenesis of Martorell HYTILU remains elusive. To reach a better understanding of Martorell HYTILU, transcriptomic analysis was conducted through RNA sequencing and immunohistochemical comparison of Martorell HYTILU (n = 17) with chronic venous ulcers (n = 4) and healthy skin (n = 4). Gene expression analysis showed a marked activation of immune-related pathways in both Martorell HYTILU and chronic venous ulcers compared with healthy skin. Notably, neutrophil activity was substantially higher in Martorell HYTILU. While pathway analysis revealed a mild downregulation of several immune pathways in Martorell HYTILU compared with chronic venous ulcers, keratinization, cornification, and epidermis development were significantly upregulated in Martorell HYTILU. Additionally, STAC2, a gene encoding for a protein promoting the expression of the calcium channel Cav1.1, was significantly upregulated in Martorell HYTILU and was detected perivascularly in situ (Martorell HYTILU n = 24; chronic venous ulcers n = 9, healthy skin n = 11). The high expression of STAC2 in Martorell HYTILU suggests that increased calcium influx plays an important role in the pathogenesis of the disease. Consequently, calcium channel antagonists could be a promising treatment avenue for Martorell HYTILU.

Kodamaea ohmeri Leg Skin Ulcer Infection in an Immunocompetent Patient: A Case Report.

INTRODUCTION: Kodamaea ohmeri is an emerging fungus recognised as an important pathogen in immunocompromised hosts, responsible for life-threatening infections. CASE PRESENTATION: We describe a case of a 69-year-old immunocompetent man with a long history of leg skin ulcers infected by K. ohmeri. This is the first case of leg wounds infected by K. ohmeri in an immunocompetent patient. The infection was successfully treated with voriconazole 200 mg daily. CONCLUSION: Though rare, K. ohmeri should be considered in patients with skin ulcers that are poorly responsive to medical treatment, even if not immunocompromised.

Associations between self-care advice and healing time in patients with venous leg ulcer- a Swedish registry-based study.

BACKGROUND: Venous leg ulcers take time to heal. It is advocated that physical activity plays a role in healing, and so does the patient's nutritional status. Additionally, malnutrition influences the inflammatory processes, which extends the healing time. Therefore, the staff's advising role is important for patient outcomes. Thus, this study aimed to investigate the associations between given self-care advice and healing time in patients with venous leg ulcers while controlling for demographic and ulcer-related factors. METHODS: The sample consisted of patients registered in the Registry of Ulcer Treatment (RUT) which includes patient and ulcer-related and healing variables. The data was analyzed with descriptive statistics. Logistic regression models were performed to investigate the influence of self-care advice on healing time. RESULTS: No associations between shorter healing time (less than 70 days) and the staff´s self-care advice on physical activity was identified, whilst pain (OR 1.90, CI 1.32-2.42, p < 0.001) and giving of nutrition advice (OR 1.55, CI 1.12-2.15, p = 0.009) showed an association with longer healing time. CONCLUSIONS: Neither self-care advice on nutrition and/or physical activity indicated to have a positive association with shorter healing time. However, information and counseling might not be enough. We emphasize the importance of continuously and systematically following up given advice throughout ulcer management, not only when having complicated ulcers.

Expanding the clinical and immunological phenotype of prolidase deficiency: A case report.

Prolidase deficiency (PD) is a rare autosomal recessive disorder associated with recurrent infections, immune dysregulation, and autoimmunity. PD is characterized by persistent dermatitis, skin fragility, and non-healing ulcerations on the lower limbs as its main dermatologic characteristics. Herein, we report a boy with PD due to a novel variant in PEPD who had abnormal facies, cognitive impairment, corneal opacity, recurrent infections, and persistent non-healing leg ulcers. Th17 lymphocyte counts and phosphorylated-STAT5 expression following IL-2 stimulation were reduced in our patient as compared to healthy control.

Negative pressure wound therapy with instillation and dwell time in debridement of fibrinous leg ulcers.

OBJECTIVE: In conjunction with appropriate wound care, negative pressure wound therapy with instillation and dwell time (NPWTi-d) may be used as an adjunct therapy for acute or hard-to-heal (chronic) wounds, especially when infected. However, there are very few data on the use of NPWTi-d in the treatment of fibrinous wounds that are difficult to debride mechanically. The main objective of this study was to describe changes in the fibrin area of such wounds, before and after treatment with NPWTi-d. METHOD: This was a monocentric, observational, prospective pilot study evaluating the NPWTi-d medical device. Eligible patients included in the study were those with hard-to-heal lower limb ulcers who had previously undergone unsuccessful specific debridement treatment for their wound, with failure of manual mechanic debridement for at least six weeks' duration, and whose wounds had a fibrinous surface area of >70% of the total wound surface area. The primary endpoint was the difference in the percentage of fibrinous surface area before and after treatment. RESULTS: A total of 14 patients who received treatment for lower limb ulcers between October 2017 and August 2019 were included in the study. There was a significant shrinkage rate of the fibrinous wound surface between the start and end of treatment (83.6±14.5% and 32.2±19.7%, respectively; p<0.001). CONCLUSION: This study showed a significant decrease in fibrin area in wounds treated with NPWTi-d, with good tolerance. We believe that NPWTi-d has its place in the multidisciplinary management of patients with hard-to-heal ulcers. Additional randomised studies are required to confirm these findings. DECLARATION OF INTEREST: The authors have no conflicts of interest.

Use of person-centred music to manage wound dressing-related pain: a mixed method case study.

OBJECTIVE: To determine whether person-centred music (PCMusic) contributes to reducing pain during painful leg ulcer dressing change procedures indicated by: decreased levels of indicators related to stress; decreased pain scores; and a more favourable treatment climate during the dressing change procedure. METHOD: A case study of a 51-year-old female patient with chronic inherited disease weakening her connective tissues. Quantitative data entailed temporal measurements of stress indicators including: heart pulse rate; oxygen saturation (SpO2); saliva cortisol; and a visual analogue scale (VAS). Qualitative data comprised phenomenological treatment descriptions and patient/licensed practical nurse (LPN) questionnaires. RESULTS: The patient's body temperature remained steady throughout all treatments. Blood pressure was excluded due to missing data. No significant pulse rate differences in relation to music/no music could be observed during treatment. Comparing PCMusic to the patient's own other music (POOM), the pulse rate was greater in both magnitude and variation when the patient listened to POOM. Oxygen saturation showed no significant difference between PCMusic and music/no music. No significant difference was observed pre-/post-debridement with music. Similarly, no significant difference was observed pre-/post-debridement with no music. Treatment with no music showed the highest VAS score; PCMusic treatments had the lowest scores. Qualitative data showed that both patient and LPNs found that PCMusic decreased pain during dressing change. CONCLUSION: The results of this case study indicate that PCMusic is a suitable complementary treatment to decrease patient pain. Patients' general health status is important when using quantitative stress/pain marker measurements. For cohort selection in future studies, we suggest healthy patients undergoing slightly painful or unpleasant treatments, patients in postoperative care and obstetric care.

Treatment of hard-to-heal wounds in ischaemic lower extremities with a novel fish skin-derived matrix.

OBJECTIVE: To evaluate the efficacy of treatment of hard-to-heal wounds of patients with ischaemia of the lower extremities, and compare an omega-3 wound matrix product (Kerecis, Iceland) with a standard dressing. METHOD: A single-centre, prospective, randomised, controlled clinical trial of patients with hard-to-heal wounds following three weeks of standard care was undertaken. The ischaemic condition of the wound was confirmed as a decreased transcutaneous oxygen pressure (TcPO2) of <40mmHg. After randomising patients into either a case (omega-3 dressing) or a control group (standard dressing), the weekly decrease in wound area over 12 weeks and the number of patients that achieved complete wound closure were compared between the two groups. Patients with a TcPO2 of ≤32mmHg were taken for further analysis of their wound in a severe ischaemic context. RESULTS: A total of 28 patients were assigned to the case group and 22 patients to the control group. Over the course of 12 weeks, the wound area decreased more rapidly in the case group than the control group. Complete wound healing occurred in 82% of patients in the case group and 45% in the control group. Even in patients with a severe ischaemic wound with a TcPO2 value of <32 mmHg, wound area decreased more rapidly in the case group than the control group. The proportions of re-epithelialised area in the case and control groups were 80.24% and 57.44%, respectively. CONCLUSION: Considering the more rapid decrease in wound area and complete healing ratio in the case group, application of a fish skin-derived matrix for treating lower-extremity hard-to-heal wounds, especially with impaired vascularity, would appear to be a good treatment option.

Treatment of bacterially contaminated lower extremity ulcers with a fatty acid-containing wound matrix: a case series.

OBJECTIVE: The aim was to evaluate the effectiveness of a marine omega fatty acid-containing multimodal wound matrix (MWM) in reducing bacterial contamination and supporting wound area reduction (WAR) in patients with hard-to-heal wounds of varying aetiologies. METHOD: A prospective, single-site, pilot case series of patients with hard-to-heal wounds. All wounds were considered non-healing prior to inclusion as they had failed to achieve at least 50% WAR after at least four weeks of standard of care (SoC) treatments. Patients were seen once weekly for wound assessments, matrix application and dressing changes. Baseline and weekly fluorescence images, standard wound images and wound measurements were obtained. RESULTS: A total of three patients, two with venous leg ulcers (VLUs) and one with a diabetic foot ulcer (DFU) were enrolled in this pilot study. The mean baseline wound age prior to study enrolment was 24 weeks, with a mean baseline wound size of 8.61cm2. The two VLUs went on to complete closure. The DFU displayed a total WAR of 53% by six weeks, when the patient was lost to follow-up due to a geographical relocation. The mean percentage area reduction of all wounds combined was 82% upon study completion. CONCLUSION: The use of MWM proved to be effective and safe in this patient cohort. The wounds included in this case series failed to enter a healing trajectory with SoC wound therapies. The MWM supported wound closure and reduced bacterial loads in this patient cohort.

Effects of concurrent optical and magnetic stimulation in hard-to-heal wounds: a real-world evidence case series.

OBJECTIVE: This work explores concurrent optical and magnetic stimulation (COMS) effects on hard-to-heal wounds in real-world settings. METHOD: In this case series, participants received COMS 1-3 times per week for up to 12 weeks alongside standard wound care. RESULTS: A total of 27 patients (18 female and nine male) were included. Mean age was 72 years. Participants' wounds that were unresponsive to standard wound care included: venous leg ulcers (VLUs, n=13); mixed leg ulcers (MLUs, n=4); diabetic foot ulcers (DFUs, n=1); pressure ulcers (PUs, n=5); and traumatic wounds (TWs, n=4). On average, COMS was applied twice a week, resulting in an overall mean wound area reduction of 69%. In 24 participants, COMS was used primarily to achieve wound closure by the end of the 12-week period, of which: 12 were classified as complete wound closure (50%; VLUs=8, PUs=3 and TW=1); four as likely-to-heal (17%; VLUs=2 and MLUs=2); four as 'improved' (17%; MLU=1, DFU=1 and TWs=2); and four as 'non-responding' (17%; VLUs=3 and MLU=1). The best results were achieved in PUs and VLUs (respectively 100% and 62% categorised as completely healed). When used in participants where its purpose was other than that of achieving wound closure, COMS was successfully used to debride two PUs, and for wound bed preparation in one TW. CONCLUSION: In this case series, COMS showed positive effects and appeared to be beneficial in healing different types of hard-to-heal wounds in community health and homecare settings. Novel COMS therapy aspects emerged: (1) positive outcomes for PU and VLU treatment; (2) COMS as a potential debridement tool when sharp debridement is unfeasible; and (3) COMS as a promising method to prepare wound beds for subsequent skin grafting or skin replacement procedures.

Treatment of an Exposed Achilles Tendon within a Refractory Mixed Arterial Venous Leg Ulcer with the Novel Use of Pericardium Allograft in Combination with Amniotic Allografting, Synthetic Extracellular Matrix, and Acellular Dermis Allografting: A Case Report.

Xenografts, commonly from porcine or bovine sources, have decades-long documented use in reconstructive surgery, including the repair of Achilles tendons. Despite decellularization processes, the risk of antigenicity with xenografts still poses a threat for graft failure. Allograft tissues reduce the risk of immune response and provide greater likelihood of successful grafting. SteriGraft® Pericardium (BSP) (Bone Bank Allografts, San Antonio, Texas) is a lyophilized allograft obtained from the pericardial sac that has undergone sterilization and processing for use in the surgical repair. The aim of this case study was to highlight the novel use of human pericardium allograft in the repair of an exposed Achilles tendon within a vascular ulceration with the concomitant use of synthetic extracellular matrix, amniotic allografting, dermal allografting, and negative pressure wound therapy to achieve healing of the wound and restoration of limb function.

Exploring the Association between Hemochromatosis and Lower-Limb Venous Disease.

OBJECTIVE: Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. METHODS: Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. RESULTS: This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. CONCLUSIONS: This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Experiences of patients living with venous leg ulcers: A qualitative meta-synthesis.

BACKGROUND: Venous Leg Ulcer is characterized by a prolonged course, delayed healing and high recurrence rate. Bringing challenges to patient treatment and care.Patients need to control the negative behavioral factors that affect wound healing and recurrence, which seriously affect their quality of life. OBJECTIVE: To integrate qualitative research related to the disease experience and feelings of patients with Venous Leg Ulcer and provide references for optimizing patient intervention measures. METHODS: We searched databases including Pubmed, CINAHL, EMBASE, Web of Science, PsycINFO, The Cochrane library, ProQuest, CNKI and Wan Fang Data from 2000 to February 2023 to collect qualitative studies on the experiences of patients living with venous leg ulcers. We used the Australian JBI evidence-based healthcare center qualitative research quality evaluation standard to evaluate the quality of literature. After quality assessment, meta-synthesis was used to summarize and explain the results. RESULTS: Sixteen studies were eligible for inclusion, and the total number of included individuals was 146. The perceptions of individuals with Venous Leg Ulcer synthesized three overarching themes and their subthemes: disease cognition (Understanding the cause of VLU,Understanding of VLU treatment, Recognition of VLU recurrence); physical experience (Pain symptoms, Other symptoms); and psychological and social experience (psychological impact, health education, economic burden, social relations, response strategies, doctor-patient/nurse-patient relationship). CONCLUSION: The lives of patients with venous leg ulcers are influenced by various complex and diverse factors. Healthcare professionals must recognize the patient's emotional needs, establish a multidimensional support system, and promote wound healing through patient self-adjustment.

Occlusive cutaneous vasculopathies as cause of chronic ulcers.

The term occluding vasculopathies covers a large number of different conditions. These often manifest as skin ulcers. Occluding vasculopathies should be considered in the differential diagnosis of leg ulcers. The term "occlusive vasculopathies" encompasses pathophysiologically related entities that share structural or thrombotic obliteration of small cutaneous vessels. In this article, we will focus on livedoid vasculopathy with and without antiphospholipid syndrome and calciphylaxis with differentiation from hypertonic leg ulcer as the most relevant differential diagnoses of leg ulcer. The term also includes vascular occlusion, for example due to oxalate or cholesterol embolism, and septic vasculopathy. This often leads to acral ulceration and is therefore not a differential diagnosis with classic leg ulcers. It will not be discussed in this article. Occlusive vasculopathy may be suspected in the presence of the typical livedo racemosa or (non-inflammatory) retiform purpura as a sign of reduced cutaneous perfusion in the wound area. Inflammatory dermatoses, especially vasculitides, must be differentiated. This is achieved by histopathological evaluation of a tissue sample of sufficient size and depth taken at the appropriate time. In addition, specific laboratory parameters, particularly coagulation parameters, can support the diagnosis.

To Mesh or Not to Mesh: What Is the Ideal Meshing Ratio for Split Thickness Skin Grafting of the Lower Extremity?

Split-thickness skin grafts can provide effective autologous wound closure in patients with dysvascular comorbidities. Meshing the graft allows for reduced donor site morbidity and expanded coverage. This study directly compares outcomes across varying meshing ratios used to treat chronic lower extremity wounds. Patients who received split-thickness skin grafts to their lower extremity for chronic ulcers from December 2014 to December 2019 at a single center were retrospectively reviewed. Patients were stratified by meshing ratios: nonmeshed (including pie crusting), 1.5:1, and 3:1. The primary outcome was clinical "healing" as determined by surgeon discretion at 30 days, 60 days, and the latest follow-up. Secondary outcomes included postoperative complications, graft loss, ulcer recurrence, progression to amputation, and mortality. A total of 321 patients were identified. Wound sizes and location differed significantly, with 3:1 meshing applied to the largest wounds (187.8 ± 157.6 cm2; 1.5:1 meshed, 110.4 ± 103.9 cm2; nonmeshed 38.7 ± 55.5 cm2; p < .0001) mostly of the lower leg (n = 18, 75%; 1.5:1 meshed, n = 23, 43.4%; nonmeshed n = 62, 25.7%; p < .0001). Meshed grafts displayed a significantly higher proportion of healing at 30 and 60 days, but no differences persisted by the final follow-up (16.5 ± 20.5 months). Longitudinally, nonmeshed STSG was associated with most graft loss (46, 19.1%; p = .011) and ulcer recurrence (44, 18.3%; p = .011). Of the 3 meshing ratios, 3:1 exhibited the lowest rates of complications. Our results suggest that 3:1 meshing is a safe option for coverage of large lower extremity wounds to minimize donor site morbidity.