Use of extracorporeal circulation in multidisciplinary approach and replantation strategies for traumatic limb amputations: A case report.

ObjectiveTo evaluate the trends in the incidence of major limb amputations and the prevalence of Dutch prosthetic users at the national level in The Netherlands between 2012 and 2021 (during the COVID-19 pandemic). Local hospitals in The Netherlands reported a doubling of major lower limb amputations during COVID-19, information about a change in the incidence of major upper limb amputations was not reported. We could not confirm this remarkable increase in major lower limb amputations in our institution, nor did we observe a change in the incidence of major upper limb amputations. We hypothesize that the COVID-19 pandemic had no effect on the number of major limb amputations. DesignObservational retrospective study analyzing national open-access databases of health insurance claims. SettingThe Dutch national opensource database www.opendisdata.nl was used to retrieve the incidence of limb amputations in the period 2012-2021, stratified by the level of amputation and the cause of amputation. The results were verified using the www.gipdatabank.nl databank. This period included 4 intervals of nationwide COVID-19 lockdowns. Participants60,848 patients who underwent limb amputations at the upper or lower extremity in the Netherlands from 2012 to 2021 (N=60,848) were included in this study. InterventionNot applicable. Main Outcome MeasuresUpper- and lower-limb amputation and prosthetic use. ResultsData were retrieved for a total of 60,848 patients in the Netherlands, who underwent 68,180 amputations of the upper and lower extremities at any level from 2012 to 2021, including 22,095 major amputations of the lower extremities. The ongoing trend of stable numbers of major lower-limb amputations from 2012 to 2019 continued in 2020 and 2021. The verification of these data at the level of prosthetic users confirmed that the annual trends were unchanged. ConclusionThe reported increased numbers of major lower-limb amputations during the COVID-19 pandemic in the Netherlands could not be confirmed using nationwide epidemiologic data.

Atrial fibrillation is the most common arrhythmia after cardiac surgery. The pathogenesis of postoperative atrial fibrillation is multifactorial. The aim of the study was to analyse preoperative, intraoperative and postoperative factors and their relationships with the occurrence and duration of atrial fibrillation. One hundred and ninety-six patients with coronary heart disease (152 men, age 62.7 ± 10.1 years) underwent surgical revascularization. Extracorporeal circulation was used in 64 patients and minimal extracorporeal circulation was used in 75 patients. Fifty-seven patients underwent surgery without extracorporeal circulation. During the first three postoperative days, subjects were monitored for the duration and incidence of atrial fibrillation, laboratory markers of inflammation (C-reactive protein, leucocytes) and serum potassium. Demographic data and associated cardiovascular diseases in the groups were not statistically different. The overall incidence of atrial fibrillation was 56% (110 patients). The highest incidence of atrial fibrillation was found in the extracorporeal circulation subgroup, with a significantly lower incidence using minimal extracorporeal circulation, and in patients operated on without extracorporeal circulation (75 vs 47 vs 46%, P <0.001). The longest duration of atrial fibrillation was found in patients operated on with extracorporeal circulation compared with minimal extracorporeal circulation, and without extracorporeal circulation (9.7 ± 11.6 vs 4.9 ± 8.3 vs 3.1 ± 5.2, P ≤0.001). The incidence of postoperative atrial fibrillation significantly correlated with elevation of inflammatory markers (C-reactive protein, leucocytes) compared with patients who were free of atrial fibrillation (P ≤0.001, P ≤0.05). The values of serum potassium were not significantly different. The relationship between postoperative atrial fibrillation and echocardiographic parameters was not confirmed. The use of extracorporeal circulation leads to a higher incidence of postoperative atrial fibrillation compared with the use of minimal extracorporeal circulation or with surgery without extracorporeal circulation, probably due to enhanced systemic inflammatory response.

Objective. Besides the early detection and treatment of diabetic foot ulcers, being aware of the risk factors for major amputation plays a crucial role in preventing the major lower limb amputations. Major lower limb amputations are not just mentally and physically hard for patients, but also have an effect on patient's survival and are a financial burden on both patients and healthcare systems. Subjects and Methods. We defined 37 potential risk factors for major amputation and these risk factors were investigated among 507 patients who had ulcers in their feet and were seen by the diabetic foot ulcer council at Ege University Faculty of Medicine. In our study, 106 (20.9%) patients ended up undergoing major lower limb amputation. Results. The univariate analysis showed that 24 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, 6 risk factors remained statistically significant. Multivariate-adjusted hazard ratios were 4.172 for hyperlipidemia, 3.747 for albumin <3.365 g/dL, 3.368 for C-reactive protein (CRP) >2.185 mg/L, 2.067 for presence of gangrenous Wagner stage, 1.931 for smoking tobacco >30 pack/year, and 1.790 for hematocrit (HCT) <31.5%. Most patients with major amputation presented with a neuroischemic foot (58%). Gender and age were not found to be risk factors for major amputation. Having less than 7% of hemoglobin A1c (HbA1c) levels had a direct proportion with major amputation numbers. The mortality rates in one year, two and three years after the major amputation operations were 24.6%, 30%, and 35.9%, respectively. Conclusion. Being familiar with these risk factors for major amputation is crucial for multi-disciplinary teams to take good care of patients with diabetic foot ulcers and to lower the need for major amputations.

Validation of the Finnvasc Score in Infrainguinal Percutaneous Transluminal Angioplasty for Critical Lower Limb Ischemia

Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: An analysis of 553 consecutive patients

Evaluation of regional variation in total, major, and minor amputation rates in a national health-care system

Living in a medically underserved county is an independent risk factor for major limb amputation

Trends in Surgical Indications for Major Lower Limb Amputation in the USA from 2000 to 2016

Off-Pump Repair of a Giant Pseudoaneurysm of a Distal Saphenous Vein Bypass Graft

Objective: To determine the frequency of postoperative complications in cardiac surgery with and without use of extracorporeal circulation (ECC). Materials and methods: this is an observacional descriptive, cross-sectional and retrospective study with 148 patients undergoing cardiac surgery with and without use of ECC, treated between 2010 to 2011. The variables were analyzed are sociodemographic characteristics, type of surgery, use of extracorporeal circulation, extracorporeal circulation time, postoperative morbidity and mortality. Results: Overall mortality it was 25 cases (16.9%) and associated with the use of ECC was 14 cases (9.45%). The morbidity associated with the use of ECC was 67 cases (57%). The most frequent complications were anemia and pleural effusion (11.1%), cardiogenic shock (9.4%), and alterations in neurological function (6.8%). It was associated with the use and long time ECC, postoperative anemia (RR: 1,45 IC95% 0,99 – 2,12), Cardiogenic shock (RR: 5,52 IC95%1,69 – 18,06), liver alterations (RR: 5,52 IC95% 0,97 – 31,25), Prolonged stay in the intensive care unit (ICU) (7,36 IC95% 3,78 – 14,34), Surgical reoperation (5,52 IC95%1,69 – 18,06) and postoperative mortality (3,35 IC95% 1,61 – 6,97). Conclusions: The use of ECC is associated with the development of more complications and mortality, it is most frequent the pleural effusion, cardiogenic shock, anemia and neurological disorders.Heart surgery without the use ECC is an alternative that has less postoperative morbidity and mortality.

To determine the epidemiology and conditions frequently seen in major lower extremity amputation. Observational study. Teaching Hospital Karapitiya, Sri Lanka, from October 2013 to September 2014. Major lower limb amputations were identified according to ICD-10 criteria. Data was retrospectively collected. Type of the amputation, indication for the amputation, gender and age of the patients, and mortality were noted. Eighty-five cases of major lower limb amputations were analyzed, including 43 above-knee amputations, 40 below-knee amputations, and 2 through-knee amputations. Most of the patients were in their 7th (38.8%, n=33) and the 8th (21%, n=18) decade of life. Female to male ratio was 1:1.7. Indications of lower extremity amputation were diabetic foot ulcer (37.6%, n=32), peripheral vascular disease (31.7%, n=27), followed by trauma (n=6), acute limb ischemia and infections (n=5 each), chronic osteomyelitis (n=4), tumors (n=3), elephantiasis, pressure sore and chronic wound (n=1 each). Overall diabetes frequency was 52.9% (n=45). In-hospital mortality rate was 9.4%. Main cause of deaths was septicemia. In the study population, major lower limb amputations were more common in males compared to females, with highest incidence in the 7th and 8th decades. Diabetes mellitus contributed to more than 50% of amputations directly or indirectly, and septicemia was responsible for the most mortality.

BackgroundMyocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients.ObjectivesTo evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization.MethodsUnicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014.ResultsSixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups.ConclusionMyocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Retrospective descriptive study of individuals with chronic limb-threatening ischemia (CLTI) admitted to the academic vascular surgery unit for a major lower limb amputation.

Lower socioeconomic status is associated with higher rates of critical limb ischemia presentation and post-revascularization amputation

Extracorporeal circulation has recently expanded outside the realm of the traditional cardiac procedures. Extracorporeal circulation and cardiopulmonary bypass has expanded to include: left and right heart long and short term support, systemic and regional hyperthermic perfusion for cancer therapy, systemic rewarming for hypothermia victims due to exposure, repair of aortic tears and aneurysms, support for respiratory failure, and more recently involvement in support of the surgical process for liver transplantation. The first orthotopic liver graft was performed by Starzl and colleagues in 1963 at The University of Colorado at Denver. Then in 1982 Starzl began utilizing veno-veno extracorporeal circulation. Vena-arterial bypass has also been utilized in other centers. Presently, the use of extracorporeal circulation in liver transplantation is being implemented in an increasing number of centers. There have been a wide range of benefits with the use of extracorporeal circulation in liver transplantation. These benefits are the control of the systemic and perihepatic circulation, greater control of volume status through efficient rapid infusion systems and decreased morbidity and mortality. The increased confidence gained by the use of extracorporeal circulation, enables patients to be referred for transplant surgery at an earlier stage, with a more reasonable prospect for a successful surgery.