Limb Salvage Using Human Placental Allografts: Adding to the Reconstructive Ladder Paradigm

Advances in plastic surgery have allowed for limb salvage in most cases of severe infection or tumor. This often involves moving adjacent or distant vascularized soft tissue into the area. Traditionally, surgeons have used the "Reconstructive Ladder" as a paradigm to consider various options to treat complex wounds. Common flaps in the lower extremity will be reviewed as well as case examples to illustrate the principles of reconstruction. New technologies such as dermal scaffolds, Negative Pressure Wound Therapy and Advanced biologics have all changed how we manage these conditions. Advances in the microanatomy of skin has allowed surgeons to design a wide array of new flaps simplifying the extent of surgical innovation. This review contains 6 figures, 2 tables, and 27 references. Keywords:lower extremity, wound, infection, tumor, osteomyelitis, sarcoma, lower extremity trauma, amputation, limb salvage

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Regenerative Limb Salvage: A Novel Technique for Soft Tissue Reconstruction of Pediatric Extremities

Journal of Reconstructive Microsurgery Open ◽

10.1055/s-0040-1718420 ◽

2020 ◽

Vol 05 (02) ◽

pp. e82-e89

Author(s):

Fouad Saeg ◽

Elvira N. Chiccarelli ◽

Hugo St. Hilaire ◽

Frank H. Lau

Keyword(s):

Soft Tissue ◽

Limb Salvage ◽

Wound Closure ◽

Perioperative Complications ◽

Statistical Significance ◽

Standard Of Care ◽

Soft Tissue Reconstruction ◽

Novel Technique ◽

Reconstructive Ladder ◽

Tissue Reconstruction

Abstract Background In complex extremity wounds, free flap-based limb salvage (fLS) is the standard of care. However, fLS is resource- and cost-intensive, and the limited availability of pediatric microsurgical expertise exacerbates these challenges. Regenerative LS (rLS) addresses these barriers to care. The aim of this study was to quantify the efficacy, safety, and cost-effectiveness of rLS in complex pediatric extremity wounds. Methods We conducted a retrospective cohort study of pediatric LS at a single hospital. Subjects were treated with fLS or rLS based on surgeon preference. Primary outcome measures were: definitive wound closure rates and time, rates of return to ambulation, number and length of procedures to achieve definitive closure, and rates of perioperative complications. Statistical analyses were performed utilizing the Wilcoxon Mann–Whitney U test with statistical significance set at p < 0.05. Results Over a 2-year period, nine consecutive patients presented with complex extremity wounds requiring fLS (n = 4) or rLS (n = 5). Demographics and wound characteristics were similar between groups. Compared with fLS, the rLS group achieved definitive wound closure 85.8% more quickly (13.8 vs. 97.5 days, p < 0.02), required 64.5% less operative time (132.6 vs. 373.0 minutes, p < 0.02), had fewer perioperative complications (0 vs. 5), and required fewer intensive care unit stays (0 vs. 1.3 days). Conclusion These data indicate that rLS is a safe and efficacious option in pediatric patients requiring soft tissue reconstruction for LS. Use of this novel technique can restore the reconstructive ladder, thereby expand patient access to pediatric LS while minimizing morbidity and reducing LS-related resource utilization.

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Surgical reconstruction for unilateral iliac artery lesions in patients younger than 50 years

VASA ◽

10.1024/0301-1526/a000151 ◽

2011 ◽

Vol 40 (6) ◽

pp. 474-481 ◽

Cited By ~ 1

Author(s):

Radak ◽

Babic ◽

Ilijevski ◽

Jocic ◽

Aleksic ◽

...

Keyword(s):

Diabetes Mellitus ◽

Limb Salvage ◽

Iliac Artery ◽

Graft Patency ◽

Long Term Results ◽

Surgical Reconstruction ◽

Safe Procedure ◽

Term Survival

Background: To evaluate safety, short and long-term graft patency, clinical success rates, and factors associated with patency, limb salvage and mortality after surgical reconstruction in patients younger than 50 years of age who had undergone unilateral iliac artery bypass surgery. Patients and methods: From January 2000 to January 2010, 65 consecutive reconstructive vascular operations were performed in 22 women and 43 men of age < 50 years with unilateral iliac atherosclerotic lesions and claudication or chronic limb ischemia. All patients were followed at 1, 3, 6, and 12 months after surgery and every 6 months thereafter. Results: There was in-hospital vascular graft thrombosis in four (6.1 %) patients. No in-hospital deaths occurred. Median follow-up was 49.6 ± 33 months. Primary patency rates at 1-, 3-, 5-, and 10-year were 92.2 %, 85.6 %, 73.6 %, and 56.5 %, respectively. Seven patients passed away during follow-up of which four patients due to coronary artery disease, two patients due to cerebrovascular disease and one patient due to malignancy. Limb salvage rate after 1-, 3-, 5-, and 10-year follow-up was 100 %, 100 %, 96.3 %, and 91.2 %, respectively. Cox regression analysis including age, sex, risk factors for vascular disease, indication for treatment, preoperative ABI, lesion length, graft diameter and type of pre-procedural lesion (stenosis/occlusion), showed that only age (beta - 0.281, expected beta 0.755, p = 0.007) and presence of diabetes mellitus during index surgery (beta - 1.292, expected beta 0.275, p = 0.026) were found to be significant predictors of diminishing graft patency during the follow-up. Presence of diabetes mellitus during index surgery (beta - 1.246, expected beta 0.291, p = 0.034) was the only variable predicting mortality. Conclusions: Surgical treatment for unilateral iliac lesions in patients with premature atherosclerosis is a safe procedure with a low operative risk and acceptable long-term results. Diabetes mellitus and age at index surgery are predictive for low graft patency. Presence of diabetes is associated with decreased long-term survival.

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Surgical and endovascular hybrid approach in peripheral arterial disease of the lower limbs

VASA ◽

10.1024/0301-1526/a000561 ◽

2016 ◽

Vol 45 (5) ◽

pp. 417-422 ◽

Cited By ~ 7

Author(s):

Anouk Grandjean ◽

Katia Iglesias ◽

Céline Dubuis ◽

Sébastien Déglise ◽

Jean-Marc Corpataux ◽

...

Keyword(s):

Mortality Rate ◽

Peripheral Arterial Disease ◽

Limb Salvage ◽

Hybrid Approach ◽

Arterial Disease ◽

Early Mortality ◽

Secondary Patency ◽

Limb Salvage Rate ◽

Peripheral Arterial ◽

Salvage Rate

Abstract. Background: Multilevel peripheral arterial disease is frequently observed in patients with intermittent claudication or critical limb ischemia. This report evaluates the efficacy of one-stage hybrid revascularization in patients with multilevel arterial peripheral disease. Patients and methods: A retrospective analysis of a prospective database included all consecutive patients treated by a hybrid approach for a multilevel arterial peripheral disease. The primary outcome was the patency rate at 6 months and 1 year. Secondary outcomes were early and midterm complication rate, limb salvage and mortality rate. Statistical analysis, including a Kaplan-Meier estimate and univariate and multivariate Cox regression analyses were carried out with the primary, primary assisted and secondary patency, comparing the impact of various risk factors in pre- and post-operative treatments. Results: 64 patients were included in the study, with a mean follow-up time of 428 days (range: 4 − 1140). The technical success rate was 100 %. The primary, primary assisted and secondary patency rates at 1 year were 39 %, 66 % and 81 %, respectively. The limb-salvage rate was 94 %. The early mortality rate was 3.1 %. Early and midterm complication rates were 15.4 % and 6.4 %, respectively. The early mortality rate was 3.1 %. Conclusions: The hybrid approach is a major alternative in the treatment of peripheral arterial disease in multilevel disease and comorbid patients, with low complication and mortality rates and a high limb-salvage rate.

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Drug-eluting stents for treatment of focal infrapopliteal lesions

VASA ◽

10.1024/0301-1526/a000170 ◽

2012 ◽

Vol 41 (2) ◽

pp. 90-95 ◽

Cited By ~ 10

Author(s):

Rastan ◽

Noory ◽

Zeller

Keyword(s):

Limb Salvage ◽

Bare Metal Stents ◽

Target Lesion ◽

Drug Eluting Stents ◽

Metal Stents ◽

Target Lesion Revascularisation ◽

Randomized Studies ◽

Drug Eluting ◽

The Mean

We have investigated the role of drug-eluting stents on patency rates after treatment of focal infrapopliteal lesions in patients with intermittent claudication and critical limb ischemia. Reports indicate that drug-eluting stents reduce the risk of restenosis after percutaneous infrapopliteal artery revascularization. A Pub Med, EMBASE, Cochrane database review search of non-randomized studies investigating patency rates, target lesion revascularisation rates, limb salvage rates and mortality rates in an up to 3-year follow-up period after drug-eluting stent placement was conducted. In addition, preliminary results of randomized studies comparing drug-eluting stents with bare-metal stents and plain balloon angioplasty in treatment of focal infrapopliteal lesions were included in this review. A total of 1039 patients from 10 non-randomized and randomized studies were included. Most commonly used drug-eluting stents were sirolimus-eluting. The mean follow-up period was 12.6 (range 8 - 24). The mean 1-year primary patency rate was 86 ± 5 %. The mean target lesion revascularization rate and limb salvage rate was 9.9 ± 5 % and 96.6 %±4 %, respectively. Results from non-randomized and preliminary results from prospective, randomized trials show a significant advantage for drug-eluting stents in comparison to plain balloon angioplasty and bare-metal stents concerning target lesion patency and in parts target lesion revascularisation. No trial reveals an advantage for drug-eluting stents with regard to limb salvage and mortality.

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