scholarly journals What Is Currently the Role of TcPO2 in the Choice of the Amputation Level of Lower Limbs? A Comprehensive Review

2021 ◽  
Vol 10 (7) ◽  
pp. 1413
Author(s):  
Judith Catella ◽  
Anne Long ◽  
Lucia Mazzolai
Keyword(s):  
Arterial Disease ◽  
Major Amputation ◽  
Lower Limbs ◽  
Limb Amputation ◽  
Quality Of Data ◽  
Amputation Level ◽  
Increased Risk ◽  
Transcutaneous Oximetry ◽  
Peripheral Arterial

Some patients still require major amputation for lower extremity peripheral arterial disease treatment. The purpose of pre-operative amputation level selection is to determine the most distal amputation site with the highest healing probability without re-amputation. Transcutaneous oximetry (TcPO2) can detect viable tissue with the highest probability of healing. Several factors affect the accuracy of TcPO2; nevertheless, surgeons rely on TcPO2 values to determine the optimal amputation level. Background about the development of TcPO2, methods of measurement, consequences of lower limb amputation level, and the place of TcPO2 in the choice of the amputation level are reviewed herein. Most of the retrospective studies indicated that calf TcPO2 values greater than 40 mmHg were associated with a high percentage of successful wound healing after below-knee-amputation, whereas values lower than 20 mmHg indicated an increased risk of unsuccessful healing. However, a consensus on the precise cut-off value of TcPO2 necessary to assure healing is missing. Ways of improvement for TcPO2 performance applied to the optimization of the amputation-level are reported herein. Further prospective data are needed to better approach a TcPO2 value that will promise an acceptable risk of re-amputation. Standardized TcPO2 measurement is crucial to ensure quality of data.

Impact of Kidney Disease on Peripheral Arterial Interventions: A Systematic Review and Meta-Analysis

2020 ◽  
Vol 51 (7) ◽  
pp. 527-533
Author(s):  
Mahesh Anantha-Narayanan ◽  
Azfar Bilal Sheikh ◽  
Sameer Nagpal ◽  
Kim G. Smolderen ◽  
Jeffrey Turner ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Meta Analysis ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Major Amputation ◽  
Early Mortality ◽  
Comorbid Condition ◽  
Increased Risk ◽  
Peripheral Arterial

Background: There are limited data on outcomes of patients undergoing peripheral arterial disease (PAD) interventions who have comorbid CKD/ESRD versus those who do not have such comorbid condition. We performed a systematic review and meta-analysis to analyze outcomes in this patient population. Methods: Five databases were searched for studies comparing outcomes of lower extremity PAD interventions for claudication and critical limb ischemia (CLI) in patients with CKD/ESRD versus non-CKD/non-ESRD from January 2000 to June 2019. Results: Our study included 16 observational studies with 44,138 patients. Mean follow-up was 48.9 ± 27.4 months. Major amputation was higher with CKD/ESRD compared with non-CKD/non-ESRD (odds ratio [OR 1.97] [95% confidence interval [CI] 1.39–2.80], p = 0.001). Higher major amputations with CKD/ESRD versus non-CKD/non-ESRD were only observed when indication for procedure was CLI (OR 2.27 [95% CI 1.53–3.36], p < 0.0001) but were similar for claudication (OR 1.15 [95% CI 0.53–2.49], p = 0.72). The risk of early mortality was high with CKD/ESRD patients undergoing PAD interventions compared with non-CKD/non-ESRD (OR 2.55 [95% CI 1.65–3.96], p < 0.0001), which when stratified based on indication, remained higher with CLI (OR 3.14 [95% CI 1.80–5.48], p < 0.0001) but was similar with claudication (OR 1.83 [95% CI 0.90–3.72], p = 0.1). Funnel plot of included studies showed moderate bias. Conclusions: Patients undergoing lower extremity PAD interventions for CLI who also have comorbid CKD/ESRD have an increased risk of experiencing major amputations and early mortality. Randomized trials to understand outcomes of PAD interventions in this at-risk population are essential.

Oral sirolimus for prevention of recurrent infrainguinal arterial obstructions after surgical and endovascular revascularizations

VASA ◽  
2008 ◽  
Vol 37 (3) ◽  
pp. 285-288 ◽  
Author(s):  
Keo ◽  
Do ◽  
Husmann ◽  
Baumgartner
Keyword(s):  
Arterial Disease ◽  
Lower Limbs ◽  
Rest Pain ◽  
Short Term ◽  
The Third ◽  
Neointimal Proliferation ◽  
Arterial Lesions ◽  
Peripheral Arterial ◽  
Case Basis

No data are currently available on the role of oral sirolimus in the prevention of recurrent stenosis in the periphery. We report the effects of oral sirolimus in the prevention of recurrent infrainguinal obstructions in patients with complex peripheral arterial disease. Three patients with ischemic rest pain of the lower limbs and repeated short-term need for surgical and/or endovascular revascularization: 9 times within 12 months, 7 times within 15 months, 11 times within 26 months, respectively. Oral sirolimus on a case by case basis, resulted in less frequent restenosis and longer intervention-free intervals: three re-interventions within 37 months in the first patient, one balloon angioplasty within 17 months in the second, and three re-interventions within 21 months in the third patient, respectively. Side effects, in particular dyspepsia and diarrhoea, were mild and tolerable. To our knowledge, this is the first report to show that oral sirolimus was successfully administered in patients with recurrent excessive neointimal proliferation after revascularization of peripheral arterial lesions lowering the necessity of re-intervention and hence prolonging intervention-free intervals.

scholarly journals Pharmacological therapy in critically ill patients with peripheral and concomitant arteriopathy

ABOUTOPEN ◽  
2018 ◽  
Vol 4 (1) ◽  
pp. 166-173
Author(s):  
Nicola Troisi ◽  
Antonio Trani ◽  
Pierluigi Antonino Cappiello
Keyword(s):  
Peripheral Arterial Disease ◽  
Clinical Manifestations ◽  
Arterial Disease ◽  
Risk Profile ◽  
Pharmacological Therapy ◽  
Lower Limbs ◽  
Limb Amputation ◽  
Critical Ischemia ◽  
Good Safety Profile ◽  
Peripheral Arterial

Peripheral arterial disease is one of the most frequent clinical manifestations of atherosclerotic disease. The clinical picture of critical ischemia of the lower limbs is often burdened by high mortality and the risk of limb amputation. The direct and indirect prostanoids, and in particular iloprost and cilostazol, are effective in the medical treatment of peripheral arterial disease. We describe here five clinical cases in which iloprost and cilostazol have been successfully administered in arterial patients with various concomitant cardiovascular diseases, highlighting a good safety profile in relation to the cardiocascular risk profile (Cardiology).

Raised Fibrinogen Levels and Outcome in Outpatients With Peripheral Artery Disease

Angiology ◽  
2017 ◽  
Vol 69 (6) ◽  
pp. 507-512 ◽  
Author(s):  
Pere Altes ◽  
Paulina Perez ◽  
Carlos Esteban ◽  
Juan Francisco Sánchez Muñoz-Torrero ◽  
Eduardo Aguilar ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Major Bleeding ◽  
Arterial Disease ◽  
Plasma Fibrinogen ◽  
Limb Amputation ◽  
Increased Risk ◽  
Factores De Riesgo ◽  
Artery Disease ◽  
Peripheral Arterial ◽  
Ischemic Events

The influence of raised fibrinogen levels on outcome in stable outpatients with peripheral arterial disease (PAD) has not been consistently investigated. We used data from the Factores de Riesgo y ENfermedad Arterial (FRENA) registry to compare ischemic events, major bleeding, and mortality in stable outpatients with PAD, according to their baseline plasma fibrinogen levels. Of 1363 outpatients with PAD recruited in FRENA, 558 (41%) had fibrinogen levels >450 mg/100 mL. Over 18 months, 43 patients presented with acute myocardial infarction, 37 had an ischemic stroke, 51 underwent limb amputation, 19 had major bleeding, and 90 died. Compared to patients with normal levels, those with raised fibrinogen levels had an over 2-fold higher rate of ischemic stroke (rate ratio [RR]: 2.30; 95% confidence interval [CI]: 1.19-4.59), limb amputation (RR: 2.58; 95% CI: 1.46-4.67), or death (RR: 2.27; 95% CI: 1.49-3.51) and an over 3-fold higher rate of major bleeding (RR: 3.90; 95% CI: 1.45-12.1). On multivariate analysis, patients with raised fibrinogen levels had an increased risk of developing subsequent ischemic events (hazard ratio [HR]: 1.61; 95% CI: 1.11-2.32) and major bleeding (HR: 3.42; 95% CI: 1.22-9.61). Stable outpatients with PAD and raised plasma fibrinogen levels had increased rates of subsequent ischemic events and major bleeding.

New possibilities of maximal revascularization of the foot as a limb salvage procedure in diabetics

VASA ◽  
2010 ◽  
Vol 39 (3) ◽  
pp. 278-283 ◽  
Author(s):  
Sauvant ◽  
Hüttenmoser ◽  
Soyka ◽  
Rüttimann
Keyword(s):  
Diabetic Foot ◽  
Arterial Disease ◽  
Major Amputation ◽  
Transluminal Angioplasty ◽  
Lower Limbs ◽  
Foot Ulcers ◽  
Diabetic Patients ◽  
Salvage Procedure ◽  
Critical Ischemia ◽  
Peripheral Arterial

Diabetics and patients with chronic renal insufficiency often have severe peripheral arterial disease of the distal lower limbs with obstructions of crural and pedal arteries and the imminent risk of critical ischemia and major amputation. Neuroischemic foot ulcers have been shown to fail to heal even after successful arterial revascularization. We report on two diabetic patients with the neuroischemic diabetic foot syndrome and different clinical outcomes after percutaneous transluminal angioplasty of chronic occluded crural arteries and discuss, whether endovascular revascularisation of infrapopliteal and pedal arteries, if possible with complete plantar arch, could promote ulcer healing in neuroischemic diabetic foot ulcers.

scholarly journals Predictors for reoperation after lower limb amputation in patients with peripheral arterial disease

VASA ◽  
2019 ◽  
Vol 48 (5) ◽  
pp. 419-424 ◽  
Author(s):  
Martin C. Berli ◽  
Florian Wanivenhaus ◽  
Method Kabelitz ◽  
Tobias Götschi ◽  
Thomas Böni ◽  
...  
Keyword(s):  
Wound Healing ◽  
Peripheral Arterial Disease ◽  
Lower Extremity ◽  
Balloon Angioplasty ◽  
Revision Surgery ◽  
Lower Limb ◽  
Arterial Disease ◽  
Limb Amputation ◽  
Amputation Level ◽  
Peripheral Arterial

Summary. Background: Major amputations in patients with peripheral arterial disease (PAD) carry a high risk for complications, including revision of the amputation, sometimes to a higher level. Determining a safe level for amputation with good wound healing potential depends largely on vascular measurements. This study evaluated potential predictive factors for revision of major lower extremity amputations in patients with PAD. Patients and methods: A retrospective chart review of all major lower extremity amputations at our institution was conducted. Amputations due to trauma or tumor and below-ankle amputations were excluded. Patient demographics, level/type of amputation, level/time of revision, comorbidities and risk factors were extracted. Results: 180 patients with PAD, mean age 66.48 (range: 31–93) years, 125 (69.4%) male were included. Most (154/180, 86.6%) underwent below-knee amputation. 71 (39.4%) patients had coronary arterial disease, 104 (57.8%) had diabetes. More than half of patients, (93/138; 51.7%) had undergone previous balloon angioplasty. 44 (30%) patients required revision surgery: 42/180 (23.3%) were revised at the same level, and in 12/180 (6.7%) a more proximal amputation was necessary. PAD stage was not associated with the level of reamputation (p = 0.4369). Significantly more patients who had previous balloon angioplasty required revision surgery (66.7% versus 45.2%, p = 0.009). 67 (37.2%) patients underwent preoperative TcPO2 measurement: 40/67 (59.7%) had TcPO2 ≥ 40 mmHg; 4/67 (6%) had TcPO2 < 10 mmHG. Three patients with TcPO2 ≥ 40 mmHg, one with 30 mmHg ≤ TcPO2 ≤ 40 mmHg and one with 10 mmHg ≤ TcPO2 ≤ 20 mmHg required re-amputation to a more proximal level. Conclusions: TcPO2 measurements are useful for determining level of lower limb amputation and predicting wound healing problems when an amputation level with TcPO2 < 40 mmHg is chosen. In transtibial amputations, TcPO2 ≥ 40 mmHg does not safely predict wound healing.

Clinical Assessment of the Patient with Claudication: The Role of the Vascular Laboratory

1997 ◽  
Vol 2 (3) ◽  
pp. 231-237 ◽  
Author(s):  
Mark A Creager
Keyword(s):  
Doppler Ultrasonography ◽  
Reactive Hyperemia ◽  
Blood Pressure Measurement ◽  
Arterial Disease ◽  
Response To Treatment ◽  
Vascular Laboratory ◽  
Transcutaneous Oximetry ◽  
Peripheral Arterial ◽  
Noninvasive Tests

The noninvasive vascular laboratory aids in the evaluation of patients with peripheral arterial disease (PAD). Several qualitative and quantitative noninvasive tests are useful for diagnosing PAD and monitoring patients' response to treatment. These tests include Doppler ultrasonography, pulse volume recording, segmental blood pressure measurement, exercise testing, post-occlusive reactive hyperemia testing, transcutaneous oximetry and color-assisted ultrasound imaging. Each test has specific utility and can be used either individually or in combination with other noninvasive tests to obtain information about the hemodynamic and functional severity of peripheral atherosclerosis in patients with claudication.

scholarly journals 652 Fate of The Contralateral Limb Following Major Lower Limb Amputation in Patients with Peripheral Arterial Disease And/Or Diabetes: Case Series from Two Regional Vascular Centres

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
H Siddle ◽  
R Bonner ◽  
P Leighton ◽  
E McGinnis ◽  
S Rahma ◽  
...  
Keyword(s):  
Peripheral Arterial Disease ◽  
Lower Limb ◽  
Case Series ◽  
Arterial Disease ◽  
Major Amputation ◽  
Limb Amputation ◽  
Contralateral Limb ◽  
Free Survival ◽  
The Mean ◽  
Peripheral Arterial

Abstract Introduction This is the first clinical case series to report time to ulceration, minor and major amputation of the contralateral limb (CLL) in the first 12 months following major lower limb amputation (LLA) in patients with peripheral arterial disease (PAD) and/or diabetes. Method Consecutive patient samples at two regional UK vascular centres were included; from 2010 to 2017 (site 1) and 2014 to 2016 (site 2). Data were extracted from electronic records for 12 months following index major LLA. Survival analyses are presented for the event of mortality in the total study population, plus major amputation-free survival, and complication-free survival in site 1 only; results are stratified by diabetes status. Results Of 381 patients reviewed (n = 197 site 1; n = 184 site 2), 208 (54.6%) were diagnosed with diabetes at the time of their index major LLA. The mean survival time of patients was lower in those without diabetes (HR: 0.64 [95% CI, 0.43 to 0.95], p=.03). The mean time to major amputation of the CLL or death in patients was lower in those without diabetes (HR: 0.65 [95% CI, 224 0.40 to 1.06]; p=.08). The median time to any complication of the CLL or death was greater in those without diabetes (HR: 1.25 [95% CI, 227 0.88 to 1.78]; p=.21). Conclusions Death rates were higher in patients without diabetes, whilst those with diabetes had high levels of CLL complications. Optimisation of care to protect the CLL following major LLA and guidance for carers, patients, and clinicians is required.

scholarly journals Lower Limb Amputation Rates in Germany

Medicina ◽  
2022 ◽  
Vol 58 (1) ◽  
pp. 101
Author(s):  
Nike Walter ◽  
Volker Alt ◽  
Markus Rupp
Keyword(s):  
Lower Extremity ◽  
Lower Limb ◽  
Arterial Disease ◽  
Lower Extremity Amputation ◽  
Lower Limb Amputation ◽  
Limb Amputation ◽  
Amputation Level ◽  
Patient Optimization ◽  
Peripheral Arterial ◽  
Extremity Amputation

Background and Objectives: The current epidemiology of lower limb amputations is unknown. Therefore, the purpose of this study was to determine (1) lower extremity amputation rates as a function of age, gender, and amputation level between 2015 and 2019, (2) main diagnoses indicating amputation, (3) revision rates after lower extremity amputation. Materials and Methods: Lower extremity amputation rates were quantified based on annual Operation and Procedure Classification System (OPS) and International Classifications of Disease (ICD)-10 codes from all German medical institutions between 2015 through 2019, provided by the Federal Statistical Office of Germany (Destatis). Results: In 2019, 62,016 performed amputations were registered in Germany. Out of these 16,452 procedures (26.5%) were major amputations and 45,564 patients (73.5%) underwent minor amputations. Compared to 2015, the incidence of major amputations decreased by 7.3% to 24.2/100,000 inhabitants, whereas the incidence of minor amputation increased by 11.8% to 67.1/100,000 inhabitants. Highest incidence was found for male patients aged 80–89 years. Patients were mainly diagnosed with peripheral arterial disease (50.7% for major and 35.7% for minor amputations) and diabetes mellitus (18.5% for major and 44.2% for minor amputations). Conclusions: Lower limb amputations remain a serious problem. Further efforts in terms of multidisciplinary team approaches and patient optimization strategies are required to reduce lower limb amputation rates.

Incidence and Predictive Factors for Amputations Derived From Charcot's Neuroarthropathy in Persons With Diabetes

2021 ◽  
pp. 153473462110258
Author(s):  
Mariana A. Bandeira ◽  
Alexandre L. G. dos Santos ◽  
Kevin Woo ◽  
Mônica A. Gamba ◽  
Vera L. C. de Gouveia Santos
Keyword(s):  
Peripheral Neuropathy ◽  
Acute Phase ◽  
Predictive Factors ◽  
Cumulative Incidence ◽  
Arterial Disease ◽  
Lower Limbs ◽  
Categorical Variables ◽  
Exact Test ◽  
Amputation Level ◽  
Peripheral Arterial

Charcot's neuroarthropathy (CN) is the progressive destruction of the bones and joints of the feet, as a consequence of severe peripheral neuropathy, which predisposes patients to amputations. The purpose of this study was to measure the cumulative incidence of amputations resulting from CN and risk factors among amputated people with diabetes mellitus (DM). This was an epidemiological, observational, and retrospective study of 114 patients with DM who had an amputation involving the lower limbs. Data were collected from 2 specialized outpatient clinics between 2015 and 2019, including socio-demographic and clinical variables (cause of amputation: CN, peripheral arterial disease [PAD], infected ulcers, fracture, osteomyelitis, and others; body mass index [BMI]; 1 or 2 DM, time since DM diagnosis, insulin treatment, glycated hemoglobin; creatinine; smoking and drinking; systemic arterial hypertension, diabetic retinopathy, diabetic kidney disease, diabetic peripheral neuropathy, acute myocardial infarction, PAD, and stroke; characteristics of amputation [level and laterality], in addition to the specific variables related to CN [time of amputation in relation to the diagnosis of CN, diagnosis of CN in the acute phase, and treatment implemented in the acute phase]). We compared socio-demographic and clinical characteristics, including types of amputation, between patients with and without CN. Statistical analyses were performed using the 2 sample t-test or Wilcoxon–Mann–Whitney test, for quantitative variables, and the Pearson's χ2 test or Fisher's exact test for categorical variables. The investigation of the possible association of predictive factors for a CN amputation was carried out through logistic regression. The amputation caused by CN was present in 27 patients with a cumulative incidence of 23.7% in 5 years. There was a statistically significant association between BMI and the occurrence of CN (odds ratio: 1.083; 95% confidence interval: 1.001–1.173; P = .048); higher values of BMI were associated with a higher occurrence of amputations secondary from CN.

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