Etiology of Limb Loss After Successful Transmetatarsal Amputation.

Comparison of Lipid Management in Patients With Coronary Versus Peripheral Arterial Disease

Lower Extremity Revascularization With Transmetatarsal Amputation Improves Healing and Reduces Major Amputation

Objectives: Patients with Peripheral artery disease (PAD) have similar cardiovascular morbidity and mortality as those with established coronary artery disease (CAD). Thus the recommended LDL goal is < 100 mg/dl for both CAD and PAD patients. This study assesses the degree of lipid control and statin drug use in CAD and PAD patients in current clinical practice. Methods: We did a retrospective chart review of patients with a diagnosis of PAD, CAD and both PAD and CAD seen at our institution between Jan 2009 to March 2012. Demographic data, lipid levels and statin use were compared between CAD, PAD and PAD & CAD groups. To enable comparison of the doses of various statins, we used statin potency unit where 1 potency unit = 10mg of Simvastatin. Results: There were a total of 11498 subjects in the chart review (CAD-9879, PAD-623, both PAD & CAD -996). PAD patients were younger with more females & lower BMI compared to CAD and both PAD & CAD groups (Table 1). Mean LDL level in the PAD group was 93.4±35.5 mg/dL, CAD group was 82.7±33.1 mg/dL and both PAD & CAD group was 80.5±31.0 mg/dL. Although all groups had a mean LDL of < 100mg/dL, significantly fewer number of PAD patients achieved target LDL <100 mg/dl and LDL <70 mg/dl, as compared to CAD and combined group (Table 1). The PAD group had significantly higher mean total cholesterol and mean LDL levels as compared to the CAD group and combined PAD & CAD group (Table 1). The mean HDL and mean triglyceride (TG) levels in PAD group were significantly higher than the CAD and combined PAD & CAD group. The PAD patients had significantly greater use of less potent statins than the CAD and PAD & CAD groups which was not compensated for by a higher mean dose of the lower potency statins (Table 1). PAD patients were receiving significantly lower mean potency unit of statins as compared to PAD and combined CAD and PAD group (Table 1). Conclusion: Even though both PAD and CAD groups had mean LDL < 100mg/dL, we found that lipid control assessed by absolute mean lipid levels were significantly better in patients with CAD and combined PAD & CAD group. Thus, our study indicates that physicians tend to be more aggressive with lipid control in patients with a diagnosis of CAD when compared to patients with PAD alone.

Peripheral arterial disease prevalence among sepsis hospitalizations and associated outcomes

This study aimed to investigate the associations of chronic kidney disease (CKD), Peripheral arterial disease (PAD) and their combined effect with all-cause and Cardiovascular disease (CVD) mortality in Chinese hypertensive...

Category:Midfoot/Forefoot; Diabetes; OtherIntroduction/Purpose:Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality.Methods:We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori.Results:The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p<.0001) or PVD (p=.0179) were all significantly associated with mortality. Patients who died were significantly older (p=.0006) and had significantly higher A1c levels (p=.0373). BMI was not significantly associated with mortality. Twenty-two patients who had 23 further amputations subsequently died.Conclusion:In our series of patients undergoing TMA, 26% underwent further amputation and 35% of patients died. Conversion rate to BKA or AKA occurred at a high rate regardless of preoperative revascularization or the use of tendo-achilles or gastrocnemius lengthening procedures. Male sex, diabetes, ESRD, history of CVD or revascularization are significant risk factors for further amputation. ESRD, diabetes, history of CVD or PVD, older age and higher A1c levels are significant risk factors for mortality. These data provide useful insight into risk factors to be emphasized when counseling patients and their families to establish realistic postoperative expectations.

Risks and Risk Factors for Ipsilateral Re-Amputation in the First Year Following First Major Unilateral Dysvascular Amputation

Transmetatarsal amputation in patients with peripheral vascular disease

LEA 25. Outcomes in Limb Preservation After Revascularization and Minor Amputations in 876 Patients With Peripheral Arterial Disease During a 9-Year Period

The optimal amputation level along the first ray in diabetic foot disorders remains disputed, particularly the choice between transmetatarsal first ray amputation and hallux amputation. This study aimed to compare mid- to long-term outcomes between these surgical approaches, focusing on ulcer recurrence and revision rates. A retrospective analysis was conducted at a tertiary care center, examining 112 patients who underwent first ray amputations between 2000 and 2023. The study compared outcomes over 5 years between transmetatarsal first ray amputation (n = 28) and hallux amputation (n = 84), which was defined as any amputation at the hallux. The primary outcome was ulcer recurrence; secondary outcomes were needed for revision surgery and revision-free survival. Multivariable Cox regression analysis was performed, adjusting for age, sex, chronic kidney disease, peripheral arterial disease, coronary heart disease, and history of contralateral amputation. Additionally, a propensity score matched analysis was conducted to control for significant baseline age differences. After a maximum follow-up of 48 months, no statistically significant difference was found in ulcer recurrence between the 2 procedures in the unmatched cohort (HR = 0.56, P = .078, 95% CI: 0.30-1.07). Similarly, no significant difference was observed in revision surgery rates (HR = 0.680, P = .189, 95% CI: 0.35-1.31). In the propensity-matched analysis, transmetatarsal amputation was associated with a significantly lower risk of ulcer recurrence (HR = 0.33, 95% CI: 0.14-0.78; P = .011). Age emerged as a significant predictor of ulcer recurrence, with each additional year associated with reduced risk (HR = 0.977, P = .001, 95% CI: 0.96-0.99). Higher stage of PAD (stage III or higher) showed lower risk of ulcer recurrence compared with lower stage (HR = 0.34, P = .01, 95% CI: 0.15-0.78). Chronic kidney disease was associated with an increase of revision (HR = 2.067, P = .018, 95% CI: 1.13-3.77 ), a history of minor amputation or conservative surgery on the contralateral side significantly increased revision risk (HR = 5.798, P = .021, 95% CI: 1.30-26.03). The study found no clear advantage of either transmetatarsal or hallux amputation regarding risk of revision surgery, whereas the risk of ulcer recurrence was significantly lower in the propensity-matched transmetatarsal amputation group.

Objective: To evaluate outcomes after transmetatarsal amputation (TMA) in peripheral arterial disease (PAD) limb salvage in an Asian population and identify risk factors associated with TMA failure.Methodology: A retrospective review of 147 patients with PAD, who had undergone TMA between 2008 and 2014, was carried out. Univariate and multivariate analysis were used to identify predictors of TMA failure. Kaplan–Meier survival analysis was used to calculate major amputation and all-cause mortality rates.Results: The mean age was 66 years. 92% were diabetic patients and 78% had preceded angioplasty. 56% of TMAs were healed via secondary intention, 8% required subsequent split-thickness skin graft closure, 24% required further debridement while 37% had wounds, which failed to heal and required below-knee amputations (BKA). Multivariate analysis showed that diabetes is the only independent predictor of TMA failure (odds ratio (OR) 7.11, p=0.064). Patients with TMA failure were at increased risk of developing nosocomial infections (p=0.025) and faced a higher risk of 30-day re-admission rate (p=0.002).Conclusion: The success rate for PAD limb salvage TMA was 63% and diabetes was an independent predictor of TMA failure. Patients with TMA failure were at increased risks of nosocomial infections, and 30-day re-admissions; hence the risks and benefits of TMA for diabetic foot limb salvage must be individualized for each patient.

Introduction: Peripheral artery disease (PAD) is a known risk factor for adverse cardiovascular outcomes and has historically been viewed as a relative contraindication to heart transplantation (HT). However, as management of PAD improves and transplant eligibility broadens, the impact of PAD on post-HT outcomes warrants reevaluation. Hypothesis: Pre-HT PAD, driven by extremity PAD, is associated with increased risk of 1-year post-HT adverse outcomes, including all-cause mortality, cerebrovascular accident (CVA), renal replacement therapy (RRT), graft dysfunction, and adverse vascular outcomes. Methods: We conducted a retrospective cohort study of patients who underwent HT at a large, advanced heart failure center from January 2012 to May 2022. PAD was defined by history of CVA, claudication, abnormal ankle-brachial index (ABI &lt;1), abnormal carotid dopplers (&gt;50% stenosis), or abnormal upper or lower extremity arterial dopplers (&gt;50% stenosis). Patients were stratified by PAD status and subtype: central/cerebrovascular (CVA or abnormal carotid dopplers) and extremity (claudication, abnormal ABI, or abnormal extremity dopplers). Outcomes included 1-year all-cause mortality, CVA, RRT, graft dysfunction (ejection fraction &lt;55%), and vascular complications (consults or abnormal imaging). Group comparisons used multivariable logistic regression adjusted for PAD subtype using Python®. Results: Of the 595 patients (mean age 53 years; 28% female; 27% Black), 216 (36%) had PAD. The PAD group exhibited higher rates of pre-HT diabetes (32% vs 21%, p&lt;0.01) and hypertension (58% vs 44%, p&lt;0.01). No significant differences in age, sex, race, kidney disease, or smoking were found between groups. In the PAD group, one-year all-cause mortality was more than double those without PAD (11.6% vs 5.5%, p=0.01). Graft dysfunction was also higher (16.7% vs 9.8%, p=0.02), while CVA (9.3% vs 8.4%, p=0.85) and RRT (15.7% vs 10.8%, p=0.11) were not significantly different in PAD patients compared to those without. PAD patients also had increased vascular complications at 1 year (15.3% vs 5.3%, p&lt;0.001). However, when stratified by PAD subtype, neither central/cerebrovascular nor extremity PAD independently predicted outcomes (Figure). Conclusion: Total PAD burden pre-HT was associated with increased all-cause mortality, graft dysfunction, and vascular complications at 1 year. These findings underscore the importance of incorporating PAD into pre- and post-HT management.

Background: A history of peripheral artery disease (PAD) is an independent predictor of cardiac mortality in patients with ischemic heart disease. However, it still remains unclear whether PAD predicts worsening heart failure (HF), cardiac and all-cause mortality in HF patients. Methods and Results: Consecutive 388 HF patients admitted to our hospital for the treatment of decompensated HF were divided into 2 groups based on the presence of PAD: HF with PAD (PAD group, n = 103) and HF without PAD (non-PAD group, n = 285). We compared echocardiographic and laboratory findings, and followed the event of worsening HF, cardiac death, non-cardiac death, and all-cause mortality between the two groups. The PAD group, as compared to non-PAD group, had 1) higher age (69.2 vs. 64.5 years old, P=0.001), 2) higher incidence of New York Heart Association functional class III or IV (56.3% vs. 37.2%, P = 0.001), 3) lower levels of hemoglobin (12.3 vs. 12.9 g/dl, P = 0.020), 4) higher levels of B-type natriuretic peptide (591.0 vs. 256.9 pg/ml, P = 0.017), 5) lower estimated glomerular filtration rate (GFR) (46.2 vs. 58.9 ml/min/1.73m 2 , P &lt; 0.001), and 6) lower left ventricular ejection fraction (42.0 vs. 48.7%, P &lt; 0.001). In the follow-up period (mean 765.6 days), Kaplan-Meier analyses (Figure) showed that the event-free survival from worsening HF, cardiac death, non-cardiac death and all-cause death was significantly higher in non-PAD group than in PAD group (P = 0.017, P &lt; 0.001, P = 0.001 and P = 0.005, respectively, by a log-rank test). In the Cox proportional hazard analyses after adjusting for age, gender, ejection fraction, estimated GFR, and the presence of ischemic heart disease, PAD was an independent predictor of cardiac death (hazard ratio (HR) 2.09, P = 0.019) and all-cause mortality (HR 2.16, P = 0.002) in HF patients. Conclusions: PAD is an independent predictor of cardiac mortality and all-cause mortality in HF patients.

Aortic valve sclerosis (AVS) is a marker of cardiovascular risk; its prevalence increases in elderly and in patients with hypertension and/or coronary arterial disease (CAD). There are no data available in patients with peripheral arterial disease (PAD) and with both CAD and PAD. To investigate the presence of AVS, 57 patients with stable CAD, 38 with PAD, and 62 with CAD + PAD where studied by echocardiography. The prevalence of AVS progressively increased within groups (P = 0.005). The prevalence of AVS in PAD doubled that in CAD group (42.1% vs. 22.8%, P < 0.05). PAD patients had a 4.634 (95% CI: 1.02-17.88; P = 0.026) fold increased risk of AVS compared to CAD. Also CAD + PAD group had a higher prevalence of aortic sclerosis when compared to CAD group (50.8% vs. 22.8%, P = 0.001). CAD + PAD showed a 3.799 (95% CI: 1.26-11.45; P < 0 .01) fold greater risk of aortic sclerosis than CAD group. There were no differences in AVS prevalence between CAD + PAD and PAD group (50.8% vs. 42.1%; P = 0.36). Age was related to AVS in both analysis (PAD vs. CAD and CAD + PAD vs. CAD: OR = 1.09, 95% CI: 1.02-1.16, P = 0.011 and OR = 1.13, 95% CI: 1.07-1.21; P < 0.001) but no classical cardiovascular risk factors. PAD patients have an elevated prevalence of AVS greater than CAD patients. In patients with both disease, the prevalence of AVS is similar to that of patients with PAD alone.

Outcome of trans-metatarsal amputations in patients with diabetes mellitus