Amputation For Peripheral Vascular Disease Research Articles

Impact of Care Fragmentation after Major Lower Extremity Amputation

Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease. Health-care Cost and Utilization Project Database for NY (2016) and MD/FL (2016-2017) were queried using International Classification of Diseases 10thedition to identify patients who underwent above the knee-, through the knee-, and below the knee-amputation for peripheral vascular disease. Patients with CF were identified as those with admissions to ≥2 hospitals during the study period. We compared the postamputation outcomes of mortality, readmission rate, length of stay (LOS) and hospital charges. We identified a total of 13,749 encounters of 2,742 patients who underwent major lower extremity amputations. There were 1,624 (59.2%) patients with CF. Patients with CF were younger (68.4years old vs. 69.7years old, P=0.005), with higher Charlson Comorbidity Indices (4.4 vs. 4.1, P<0.001), and required more hospital resources on index admission ($113,699 vs. $91,854, P<0.001). These patients were prevalent for higher 30-, and 90-day readmission rates (34.7% vs. 24.5%, P<0.001 and 54.7% vs. 42.0%, P<0.001, respectively). On their first postamputation readmission, LOS (16.3days vs. 14.7days, P=0.004) and hospital charge ($48,964 vs. $44,388, P=0.002) were significantly higher. Multivariate regression analysis demonstrated that the CF was an independent predictor for 30-day (hazard ratio (HR) 1.65, 95% confidence interval (CI) 1.39-1.96, P<0.001) and 90-day (HR 1.66, 95% CI 1.42-1.95, P<0.001) readmission after the major lower extremity amputation, but not for mortality (HR 0.83, 95% CI 0.56-1.23, P=0.36). CF after major lower extremity amputation is associated with higher readmission rate, LOS, and hospital charge. Collaboration of care providers to maintain continuity of care for peripheral vascular disease patients may enhance quality of care and reduce health care cost.

Impact Of Care Fragmentation After Major Lower Extremity Amputation

Care fragmentation (CF) is a known risk factor for unplanned readmission, morbidity, and mortality after surgery. The goal of this study was to evaluate the impact of CF on outcomes of major lower extremity amputation for peripheral vascular disease.

Opioid utilization after lower extremity amputation for peripheral vascular disease and discharge prescribing recommendations.

Opioids are commonly used for pain control after lower extremity amputations (LEA)-below the knee amputations (BKA) and above the knee amputations (AKA). Well-defined benchmarks for prescription requirements after amputation are deficient. This analysis evaluated opioid utilization after amputation to identify high-risk patients and provide recommendations for post-hospitalization opioid prescriptions at discharge. Patients undergoing LEA (2008-2016) with identified peripheral vascular disease were selected from Cerner's Health Facts® database using ICD-9 and 10 diagnosis and procedure codes. Patient demographics, disease severity, comorbidities, and hospital characteristics were evaluated. Post-operative opioid medications administered intravenously and orally during the hospital stay were identified from the data and converted to Morphine Milligram Equivalent per day (MME/d) for an evaluation and comparison during the index hospitalization. Descriptive statistics were used to report continuous and dichotomous variables. Dichotomous variables are reported as n (%) and continuous variables are reported as mean ± standard deviation (SD). Chi-square and T-tests were used as appropriate. 2399 patients who underwent AKA or BKA with peripheral vascular disease were evaluated. Sixty-three percent of the cohort was male, 67% Caucasian, and 42% married, and 58% had a Charlson index >3. The majority of patients had an average length of hospital stay of 5.7 days (M = 5.72, SD = 4.56). Patient groups that used significantly higher MME/d in the early postop period included: BKA (29.2 vs 20.7, p = 0.006), males (62.6 vs 54.0, p < 0.0001), Caucasians (64.3 vs 44.7, p < 0.0001), younger patients (69.6 vs 54.0, p < 0.0001), and those at non-training institutions (66.7 vs 56.7, p < 0.0001). Patients whose hospital stay was greater than 6 days were found to have increased opioid utilization likely secondary to index complications. For those discharged by post-operative day 7, the mean MME utilized on postop day 1 was 59.5 and decreased to a mean MME/d utilization prior to discharge of 17.6. This analysis demonstrates that younger patients, males, patients with BKAs, and those who receive amputations for vascular disease at non-training institutions have higher post-operative opioid utilization during the hospital stay. At the time of discharge, patients utilized an average of 17.6 MME/d which equates to approximately three hydrocodone/acetaminophen 5/325mg tablets per day. Based on these findings, vascular surgeons are likely over prescribing opioids at discharge and must be cognizant of appropriate dosing quantities. Prescriptions at discharge should reflect the daily utilization described from this analysis and tapered to avoid chronic utilization, overdose, and possible death.

O42: THE ROLE OF TOURNIQUETS IN TRANSTIBIAL AMPUTATION FOR PERIPHERAL VASCULAR DISEASE: A SYSTEMATIC REVIEW &amp; META-ANALYSIS

Abstract Introduction The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease. Method This systematic review was conducted according to PRISMA guidelines. A systematic search of Medline, Embase and Cochrane Library was undertaken for articles which compared the use of a tourniquet versus no tourniquet in patients undergoing trans-tibial amputation for peripheral vascular disease. The main outcomes included intra-operative blood loss, post-operative transfusion requirement, need for revision surgery and 30-day mortality. Result Four studies met the inclusion criteria for quantitative analysis with a total of 267 patients. A tourniquet was used in 130 patients. Both groups were matched for age, gender, co-morbidities and pre-operative haemoglobin. In patients undergoing trans-tibial amputation, tourniquets were associated with significantly lower intra-operative blood loss (Mean difference= -147.6mls; P=0.03) and lower transfusion requirements (pooled odds ratio (OR), 0.12, p=0.03). The need for stump revision (OR, 0.7; p=0.48), proceeding to transfemoral amputation within 30 days (OR, 0.67; p=0.25) and 30-day mortality (OR, 0.65; p=0.41) all favoured tourniquet use but the differences were not found to be significant. Conclusion Tourniquets can reduce intra-operative blood loss and transfusion requirements in patients undergoing trans-tibial amputation without increasing ischaemic complications and need for revision surgery. Take-home message Tourniquets are safe to use in trans-tibial amputation for severe peripheral vascular disease and can reduce intra-operative blood loss without increasing ischaemic complications.

EFFECTIVENESS OF INTRAOPERATIVE PLACEMENT OF A PERINEURAL NERVE CATHETER IN PATIENT ROAD TO RECOVERY

Post surgical pain after major lower limb amputation is a major problem to the patients recovery. The majority of patients require continuous opioid analgesics and NSAIDs after surgery, which are associated with side-effects. In order to overcome the pain encountered by these patients, we routinely practice intraoperative placement of aNerve catheter along the peripheral nerve stump. The anesthetic medication is used to calm the nerves and overcome pain perceived by the patient. We study the effectiveness of pain control and reduction in the need for oral / parenteral administration of analgesics. This step could potentially reduce post-procedure analgesics usage and other related adverse effects. Methods: A retrospective study and data review of 98 patients who had major lower limb amputation for peripheral vascular disease over a 5-year duration. Intra-operatively, 42 patients had a perineural catheter placement were compared to 56 patients who had oral and parenteral analgesics prescribed to treat post operative pain. The primary outcomes of this studywere the number and quantity of drug needed in the first 4 days postoperatively and swiftness in postoperative recovery to do rehabilitation. Results: 98 major lower-limb amputations were selected. Analysis shows that perineural catheter use was associated with a decreased need for postoperative analgesics and decreased postoperative pain scores at 72 hours. Perineural catheter use led to a 65% reduction inopioid + NSAIDs use during the early postoperative period. Data also suggests the patient tend to fair better in rehabilitation work with nerve catheter placement. Conclusions: Post operative continuous infusions of local anesthetic through nerve catheter are safe and effective in reducing pain post-amputation. The analgesic medications requirement after major lower limb amputation can be significantly lowered so are the complications.

AB039. The role of tourniquets in trans-tibial amputation for peripheral vascular disease—a systematic review &amp; meta-analysis

Background: The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease.

The Perineural Local Anaesthetic Catheter After Major Lower Limb Amputation Trial (Placement): A Randomised Controlled Feasibility Study

Introduction - Pain control after major lower limb amputation for peripheral vascular disease is a significant problem, due to the multifactorial nature of post-amputation pain, contra-indication of epidural anaesthesia in many patients and side effects of opioid analgesics and patient frailty. A perineural catheter is a thin plastic tube which may be placed adjacent to the sciatic or tibial nerve at the time of amputation, through which a continuous local anaesthetic infusion can be given. Although low quality observational data suggest that perineural catheter usage reduces postoperative opioid requirements, little data are available regarding their effect on pain. PLACEMENT is a randomised controlled feasibility study to explore the feasibility of running a multi-centre effectiveness trial to assess the impact of perineural catheter usage on short and medium term postoperative outcomes. Methods - Fifty patients undergoing major lower limb amputation (at below or above knee level) for peripheral vascular disease were recruited from two centres. Patients were randomised in a 1:1 ratio to receive standard postoperative analgesia, with or without insertion of a perineural catheter and local anaesthetic infusion for up to 5 postoperative days. The primary effectiveness outcome was pain measured on a verbal rating scale in the first five post-operative days. Secondary effectiveness outcomes included quality of life and the prevalence of phantom limb and chronic stump pain assessed 2 and 6 months after surgery as well as total healthcare costs. Key feasibility outcomes included the proportion of eligible patients successfully recruited and the feasibility of using pain scores as a primary outcome measure as well as a preliminary estimate of the effect size. Full ethical approval has been granted (Wales REC 3 reference number 16/WA/0353). The trial is registered as ISRCTN85710690 with EudraCT number 2016-003544-37 and is funded by Health and Care Research Wales (grant number RfPPb-16-1198). Results - Recruitment commenced on 15th February 2017 and 50 patients were successfully enrolled in the study across two centres by 15th November 2017. Follow-up is due to complete in May 2018, and results of the primary effectiveness and key feasibility outcomes will be available in time for the annual meeting of the European Society for Vascular Surgery, where they will be made publically available for the first time. Conclusion - PLACEMENT is a multi-centre randomised controlled feasibility study which is the first to explore the feasibility of running an effectiveness trial on perineural catheter usage for postoperative pain in amputees. Recruitment is complete and full trial results will be available in time for the annual meeting of the European Society for Vascular Surgery.

Factors influencing short‐ and long‐term mortality after lower limb amputation

Mortality after lower limb amputation is high, with UK 30-day mortality rates of 9-17%. We performed a retrospective analysis of factors affecting early and late outcome after lower limb amputation for peripheral vascular disease or diabetic complications at a UK tertiary referral vascular centre between 2003 and 2010. Three hundred and thirty-nine patients (233 male), of median (IQR [range]) age 73 (62-79 [26-92]) years underwent amputation. Thirty-day mortality was 12.4%. On regression modelling, the risk of 30-day mortality was increased in patients of ASA grade ≥4 (OR 4.23, 95% CI 2.07-8.63), p<0.001 and age between 74 and 79years (OR 3.8, 95% CI 1.10-13.13), p=0.04 and older than 79years (OR 4.08, 95% CI 1.25-13.25), p=0.02. Peri-operative (30-day) mortality for these groups was 23.2%, 13.7% and 18.8%, respectively. Survival and Cox regression analysis demonstrated that long-term mortality was associated with: age 74-79years (HR 2.15, 95% CI 1.38-3.35), p=0.001; age >79years (HR 2.78, 95% CI 1.82-4.25), p<0.001; ASA grade ≥4 (HR 2.04, 95% CI 1.51-2.75), p<0.001; out-of-hours operating (HR 1.51, 95% CI 1.08-2.10), p=0.02; and chronic kidney disease stage 4-5 (1.57, 95% CI 1.07-2.30), p=0.02. Anaesthetic technique was associated with long-term mortality on survival analysis (p=0.04), but not when analysed using regression modelling. Mortality after lower limb amputation relates to patient age, ASA, out-of-hours surgery and renal dysfunction. These data support lower limb amputations' being performed during daytime hours and after modification replace with 'of' correctable risk factors.

Through-knee amputation in peripheral vascular disease

Through-knee amputation accounts for just 2.8% of annual amputations in England. Traditionally it is viewed as an operation with poor outcomes, and its use limited. We present a case series and review of articles published on through knee amputation. The literature review covers the 17 papers identified on through-knee amputation in peripheral vascular disease. The results are summarised and discussed, with favourable outcomes in terms of perioperative mortality and primary healing demonstrated in the majority of papers. In the case series, 14 patients who underwent through knee amputation were retrospectively reviewed. Peri- operative mortality was 7%. Primary healing was achieved in 79% of cases. Functional outcomes were excellent, with predicted functional activity achieved in 81% of survivors, with 34% ambulating regularly. In conclusion, through-knee amputation should be considered as an alternative to transfemoral amputation, as perioperative mortality, healing rates and functional outcomes appear excellent, both in this series and the majority of others published.

Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes

Information about longer-term functional outcomes following lower extremity amputation for peripheral vascular disease and diabetes remains limited. This study examined factors associated with mobility success during the first year following amputation. Prospective cohort study of 87 amputees experiencing a first major unilateral amputation surgery. Seventy-five (86%) participants completed 12-month follow-up interview. Twenty-eight subjects (37%) achieved mobility success, defined as returning to or exceeding a baseline level of mobility on the locomotor capability index (LCI-5). Forty-three subjects (57%) were satisfied with their mobility. Individuals who were 65 years of age and older (risk difference [RD] = -0.52; 95% confidence interval [CI]: -0.75, -0.29), reported a current alcohol use disorder (RD = -0.37; 95% CI: -0.48, -0.26), had a history of hypertension (RD = -0.23; 95% CI: -0.43, -0.03) or treatment for anxiety or depression (RD = -0.39; 95% CI: -0.50, -0.28) were less likely to achieve mobility success. Mobility success was associated with mobility satisfaction (RD = 0.36; 95% CI: 0.20, 0.53) and satisfaction with life (RD = 0.28; 95% CI: 0.06, 0.50). Although higher absolute mobility at 12 months was also associated with mobility satisfaction and overall life satisfaction, 50% of individuals who achieved success with low to moderate 12-month mobility function reported they were satisfied with their mobility. Defining success after amputation in relation to an individual's specific mobility prior to the development of limb impairment which led to amputation provides a useful, patient-centered measure that takes other aspects of health, function, and impairment into account.

Pre-emptive Analgesia for Chronic Limb Pain After Amputation for Peripheral Vascular Disease: A Systematic Review

Pre-emptive Analgesia for Chronic Limb Pain After Amputation for Peripheral Vascular Disease: A Systematic Review

Pre-emptive Analgesia for Chronic Limb Pain After Amputation for Peripheral Vascular Disease: A Systematic Review

Chronic stump and phantom limb pain after amputation for critical ischemia significantly affect patients' quality of life and pose challenging clinical problems. Pre-emptive analgesia attempts to prevent chronic postoperative pain by minimizing painful stimuli before and during surgery. This systematic literature review aimed to evaluate the evidence supporting the use of pre-emptive analgesia in minimizing the risk of chronic stump and phantom pain after lower limb amputation for critical ischemia of peripheral vascular disease. A total of 11 studies have been retrieved. Five different types of analgesic drugs were evaluated (local anesthetics, opiates, N-methyl-D-aspartate receptor antagonists, a(2)-agonist, and gamma-aminobutyric acid analogues), administered separately or in combinations, through the oral, intravenous, epidural, or regional (perineural) route. The beneficial effect of combined bupivacaine, diamorphine, and clonidine in reducing the risk of phantom limb pain was supported by only one study (level 3 evidence). Epidural and perineural infusions containing local anesthetic ± opiates are effective in treating acute perioperative pain, although not without potentially serious complications. Most studies were characterized by high drop-out rates because of disease-associated mortality. There is no robust evidence supporting the use of pre-emptive analgesia to minimize the risk of chronic pain after amputation for critical ischemia of peripheral vascular disease. The methods used are, however, effective in treating acute postoperative pain.

Outcomes of a Standardized Surgical and Rehabilitation Program in Transtibial Amputation for Peripheral Vascular Disease

To study the outcomes of a new surgical and rehabilitation program for initial unilateral transtibial amputation in patients with peripheral vascular disease. The program consists of sagittal incision, rigid dressing, compression therapy using silicone liner, and direct manufacturing prosthetic technique. A prospective cohort study with 1-yr follow-up. Of the 217 consecutive patients with peripheral vascular disease who underwent transtibial amputation (mean age, 77 yrs; 51% diabetic; 116 could walk before amputation), 119 (55%) were fitted with a prosthesis at a median time of 41 (range, 12-147) days after amputation. Of the prosthetic recipients, 76 (64%) obtained good function with the prosthesis within 6 mos. Within 1 yr, reamputation was performed on 8.2%, and contralateral amputation was performed on 5.5%. The 90-day mortality was 24% (53 patients). The total 1-yr mortality was 40% (86 patients): 17% among patients who received a prosthesis and 67% among those who did not receive a prosthesis or had undergone reamputation. Following this standardized surgical and rehabilitation program, prosthetic fitting was achieved in more than half of transtibial amputees, almost two-thirds of prosthetic recipients obtained good function, and the reamputation rate was low. Comparison with outcomes of alternative strategies is needed.

Comparison of Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysms From the ACS-NSQIP 2005–07

To compare endovascular (EVAR) and open surgical repair (OSR) for ruptured abdominal aortic aneurysms (RAAA) in terms of preoperative hemodynamic status and comorbidities. The 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was interrogated to find all patients undergoing repair for RAAA. Of the 567 RAAA repairs identified, 121 (21%) were endovascular and 446 (79%) were open. Demographics, comorbidities, and preoperative hemodynamic status were compared by repair method. Age, sex, and race were similar between repair cohorts. EVAR patients had greater incidences of recent myocardial infarction (7% versus 2%, p<0.05), revascularization or amputation for peripheral vascular disease (8% versus 3%, p<0.05), and cerebrovascular disease (22% versus 11%, p<0.01). Preoperative hemodynamic status was similar based on need for >4 units of blood (3% versus 6%, p = 0.31), intubation (12% versus 17%, p = 0.18), impaired sensorium (7% versus 11%, p = 0.25), coma (4% versus 5%, p = 0.65), acute renal failure (2% versus 2%, p = 0.60), and ASA class 5 (29% versus 34%, p = 0.29). Open repair was associated with greater operative time (3.3 versus 2.6 hours, p<0.01) and intraoperative blood transfusions (8 versus 2 units, p<0.001). Overall mortality was 33.5% (EVAR 24% versus OSR 36%; OR 1.8, 95% CI 1.1 to 2.8, p<0.05). After adjusting for preoperative comorbidities and all preoperative hemodynamic variables, mortality after open repair was greater than after EVAR (OR 1.9, 95% CI 1.1 to 3.2, p<0.05). Overall postoperative complications were greater after open repair (62% versus 47%, p<0.01). Graft failure requiring reintervention was higher after EVAR (4% versus 1%, p<0.05), while rates of return to the operating room for a major operation were similar (21% versus 24%, p = 0.43). For RAAA within NSQIP hospitals in recent years, preoperative hemodynamic status was similar between EVAR and OSR, but EVAR patients had greater comorbidities. Despite this and after accounting for minor differences in hemodynamic status, EVAR mortality was lower than OSR mortality. Institutions with adequate experience and resources should attempt endovascular repair for RAAA when anatomy allows.

Improper Use of a Transtibial Prosthesis Silicone Liner Causing Pressure Ulceration

We present the previously unreported hazard of creating pressure ulceration in a susceptible host by the improper use of a silicone prosthetic liner. An 80-yr-old man sustained a recent transtibial amputation for peripheral vascular disease. His comorbidities included vascular cognitive impairment, type 2 diabetes mellitus, coronary artery disease, anemia of chronic disease, postherpetic neuralgia, and pruritus of uncertain origin. When not using his transtibial prosthesis, he found his 1.5-mm thick silicone liner (ICEROSS) more comfortable to wear than his stump shrinker and thermoplastic protector. Moreover, he repeatedly wore his liner rolled partway down his stump to allow him to scratch pruritic skin. A horizontal, linear, stage 2 ulcer developed on the residual limb under the upper edge of the rolled liner. The ulcer required >3 mos to heal. This case illustrates the importance of candidate selection for roll-on liners, proper patient and professional training, and optimal management of patient comorbidities.

Lethal cause of abdominal pain: a diagnosis not to be missed

A 77-year-old woman was brought to the accident and emergency department with a 11-day history of abdominal pain. She was in shock and required resuscitation. She had attended the accident and emergency a few days before and had been discharged home with a diagnosis of non-specific abdominal pain. The previous abdominal X-ray is shown in Figure 1. Her past medical history included bilateral below knee amputation for peripheral vascular disease, pacemaker for heart block and hypertension. On examination, post-resuscitation, she was confused and apyrexial with a heart rate of 100 beats/minute and a blood pressure of 110/70 mmHg. Her abdomen was diffusely distended with minimal tenderness in the epigastrium and supra-umbilical region. There was no rigidity or guarding. Bowel sounds were normal. Digital rectal examination showed soft faeces. Blood test showed a haemoglobin of 6.6 g/dl (down from 11 g/dl during her previous accident and emergency visit). There was slight impairment of renal function with a urea of 11 mg/dl and creatinine of 160 mg/dl. The rest of the blood tests were within normal limits. Arterial blood gases showed metabolic acidosis with a pH of 7.2 and lactate of 3 mmol/litre. A computed tomography scan of the abdomen was performed. 1. What is the differential diagnosis? 2. What can you find in the abdominal X-ray? 3. What can you find in the computed tomography scan? 4. What is the treatment? 5. What is the prognosis of this patient? The differential diagnoses in this case are peritonitis from hollow viscus perforation, ischaemic bowel and leaking abdominal aortic aneurysm. The abdominal X-ray (Figure 1) shows minimal dilatation of the right and transverse colon and a tortuous calcified aorta. However the upper aortic calcification is not obvious. Computed tomography scan shows an abdominal aortic aneurysm which commences immediately distal to the origin of the right renal artery with not involving the bifurcation. There is leakage from this aneurysm (Figure 2b arrow) which has a maximum diameter of 5 cm. There is a periaortic haematoma which extends anteriorly to displace the loops of bowel anteriorly (Figure 2b). There is free fluid in the peritoneal cavity (Figure 2a). The right kidney is well perfused but the left kidney shows no evidence of perfusion (Figure 2c). There are some calculi in the left pelvis. In this patient, palliation was felt to be the most appropriate treatment option (her case was discussed with the on-call vascular surgeons). The patient died a few hours after her hospital admission. In a relatively fitter patient, open surgery is the treatment of choice.

Comparison of vacuum‐formed removable rigid dressing with conventional rigid dressing after transtibial amputation

Background and purpose Following transtibial amputation, a rigid dressing of plaster of Paris has been reported to have advantages over a soft dressing regarding wound healing and reduction of edema, but use of the former may be limited by difficulties in application and in gaining access to the wound. An easily applicable and removable vacuum‐formed rigid dressing (ORD) has recently been introduced. We compared the ORD with a conventional rigid plaster of Paris dressing with regard to wound healing, time to fitting of a prosthesis, and function with the prosthesis.Method Patients undergoing transtibial amputation for peripheral vascular disease were randomized at surgery to receive ORD (O) or conventional rigid dressing (C) for 5 to 7 days, followed by compression therapy using silicone liner. The primary outcome measure was time to prosthetic fitting and secondary outcome measures included function with the prosthesis 3 months after amputation, measured with the Locomotor Capability Index (LCI) and the Timed “Up and Go” (TUG) test. All patients received prostheses with a total surface‐bearing socket.Results Of 27 patients randomized to one or other dressing (15 O and 12 C), prosthetic fitting was achieved in 23 patients (mean age 76 (43-91) years; 13 (9 men) in the O group and 10 (5 men) in the C group). Wound healing was similar in both groups. Mean time to prosthetic fitting was 37 (26-54) days in the O group and 34 (21-47) days in the C group (adjusted mean difference 3, 95% CI: -3-9). At 3 months, mean LCI was 28 (6-42) in the O group and 25 (2-41) in the C group (mean difference -0.1, 95% CI: -8.5-8.2). Mean TUG was 41 (10-92) seconds and 29 (10-47) seconds, respectively (mean difference 14, 95% CI:-2-30).Interpretation The vacuum‐formed rigid dressing appears to give results similar to those of the conventional rigid dressing regarding time to prosthetic fitting and patient's function with prosthesis.

Prospects for Percutaneous Valve Therapies

Developmental efforts to achieve percutaneous catheter-based therapies for cardiac valve repair and replacement have advanced rapidly over the past several years. A variety of methods to treat mitral regurgitation (MR) and to replace aortic and pulmonic valves have already been successfully employed in patients. These innovative clinical transcatheter valve therapies were anticipated more than a decade ago by creative experimentalists who helped develop predicate techniques in animal models. For example, in 1992, a catheter-delivered ball-in-cage prosthetic aortic valve was implanted in a canine model by Pavcnik1 and a stent-mounted bioprosthetic valve was placed by Andersen, who used a retrograde transarterial approach in a swine model.2 Clearly, the catheter-based technologies used in clinical studies today in patients with aortic stenosis were derived from the fusion of known successful aortic valve replacement (AVR) surgical devices and adaptive interventional modalities, first studied in experimental animal models. Similarly, approaches for transcatheter treatment of MR have also borrowed heavily from preexisting and accepted surgical techniques, such as the edge-to-edge leaflet coaptation technique and reduction ring mitral annuloplasty.3 Importantly, recognition that the coronary sinus parallels the mitral annulus has spurred unique catheter-based transvenous approaches to treat MR by indirectly reducing mitral annular dimensions.4 Because many of the new percutaneous approaches to valve therapy have been developed by surgeons, a collaboration has emerged between thoughtful surgeons and interventionalists, combining skill sets and experiences to accelerate the developmental pathways of less-invasive transcatheter valve therapies. Growing recognition exists that percutaneous alternatives to surgical therapies are required in some patient subgroups with valvular heart disease. Among patients with either mitral and/or aortic valve disease, an expanding population of elderly patients with significant comorbidities may benefit from traditional surgical methods, but these methods are associated with unacceptable perioperative mortality or prolonged postoperative recoveries. In the EuroHeart Survey …

Guidelines for the treatment of arterial insufficiency ulcers

1. Co-chaired panel 2. University of Utah, Salt Lake City, UT 3. University of Texas, San Antonio, TX 4. Sinai Hospital/Johns Hopkins Medical Institutions, Baltimore, MD 5. GKT School of Medicine, King’s College, London, UK 6. University of Texas Health Science Center at Houston, TX 7. Sequoia Hospital, Redwood City, CA 8. Maricopa Medical Center, Phoenix, AZ 9. Tufts-New England Medical Center, Boston, MA 10. Southampton University Hospitals Trust NHS, Southampton, UK 11. Penrose–St. Francis Health Services, Colorado Springs, CO 12. Beverly Surgical Associates, Beverly, MA 13. Saint Francis Memorial Hospital, San Francisco, CA 14. Northbay Center for Wound Care, Vacaville, CA, and 15. University of California, San Francisco, CA

Prediction of amputation wound healing: the role of transcutaneous pO2 assessment.

With the recent trend towards more distal lower limb and below-knee amputation for peripheral vascular disease, failure of amputation healing remains a common clinical problem. There is an urgent need for more objective measures of selecting the most appropriate distal amputation level compatible with healing. Oxygen availability is the final arbiter of tissue viability and healing potential, and we have shown that the measurement of transcutaneous pO2 (TcpO2) accurately reflects the degree of ischaemia in the lower limb. In 59 patients having 62 amputations for peripheral vascular disease significantly lower TcpO2 levels were related to amputation failure. Below-knee amputations with a pre-operative below-knee TcpO2 of above 35 mmHg always healed, and failures had levels of 35 mmHg or less. Nine out of sixteen patients having above-knee amputations had pre-operative below-knee TcpO2 values well above 35 mmHg, suggesting that they may possibly have undergone successful below-knee amputation. No correlation between ankle systolic pressure and amputation healing was found. TcpO2 measurement is simple, non-invasive and reliable and offers an exciting research advance in the assessment of effective tissue perfusion.