Difference In Amputation Research Articles

Jetstream Atherectomy with Paclitaxel-Coated Balloons: 3-Year Outcomes of the Prospective Randomized JET-RANGER Study

AbstractThe JET-RANGER study (NCT03206762) was a multicenter (11 U.S. centers), randomized trial, core-lab adjudicated and designed to demonstrate the superiority of Jetstream + paclitaxel-coated balloon (JET + PCB) versus percutaneous transluminal angioplasty (PTA) + PCB in treating femoropopliteal arterial disease. The 1- and 2-year outcomes have been recently published. The 3-year outcome data are presented in this report. The JET-RANGER trial initially had 47 patients with 48 lesions. Thirty-one in the JET-PCB arm and 16 in the PTA + PCB arm (2:1 randomization). At 3-year follow-ups, there were 20 patients in the JET-PCB arm and 14 patients in the PTA + PCB arm. Kaplan–Meier survival analysis was performed to estimate the freedom from target lesion revascularization (TLR) at 3 years. Bailout stenting was not considered a TLR in this analysis. Statistical significance was determined by a p-value < 0.05. Freedom from TLR was statistically similar between the two groups at 3 years between JET + PCB and PTA + PCB (freedom from TLR was 88.0 vs. 67.8%, respectively, p = 0.1380). There was also no significant difference in the change of ankle-brachial index (ABI) between the PTA + PCB and JET + PCB from baseline at 6 months (p = 0.7890), 1 year (p = 0.4070), 2 years (p = 0.7410), and 3 years (p = 0.8010). There was also no statistical difference between the JET + PCB and PTA + PCB arms for RCC improvement by one or more categories from baseline to 3 years (p = 0.8949). There were no minor or major amputations for either arm throughout the 3-year follow-up. Five JET + PCB patients died before the 3-year specified window and none in the PTA + PCB arm (p = 0.137). Two of the deaths were due to cancer and three due to cardiac causes. None were deemed related to the device or procedure. JET + PCB had similar freedom from TLR and improvement in ABI and RCC at 3-year follow-up with no difference in amputation or mortality between the 2 arms. A trend toward less TLR was seen in the JET + PCB arm.

A Systematic Review and Meta-Analysis of Efficacy and Safety of Cilostazol Prescription in Patients With Femoropopliteal Peripheral Artery Disease After Endovascular Therapy.

The purpose of this study is to assess the efficacy and safety of cilostazol prescription in patients with femoropopliteal peripheral artery disease (PAD) after endovascular therapy (EVT). We conducted a systematic review and meta-analysis of all studies reporting the outcomes of cilostazol after femoropopliteal EVT of PAD up to September 2022. Clinical outcomes of interest included primary patency, in-stent restenosis (ISR), vessel re-occlusion, freedom from target lesion revascularization (TLR), repeat revascularization, all-cause mortality, amputation, major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs), and bleeding complication. A total of 4 randomized controlled trials (RCTs) and 8 observational studies containing a total of 4898 patients met the inclusion criteria and were included in this systematic review and meta-analysis. We found that the use of cilostazol was associated with higher primary patency after femoropopliteal artery EVT (odds ratio [OR]=1.67, 95% confidence interval [CI]=1.50-1.87, p<0.001, I2=33.2%), a lower risk of ISR (OR=0.43, 95% CI=0.29-0.63, p<0.001, I2=37.6%), repeat revascularization (OR=0.43, 95% CI=0.24-0.76, p<0.005, I2=27.4%), and vessel re-occlusion (OR=0.59, 95% CI=0.38-0.93, p<0.05, I2=0%). There was an increase in freedom from TLR rate (OR=2.19, 95% CI=1.58-3.05, p<0.001, I2=0%), as well as a reduction in the occurrence of MALEs (OR=0.50, 95% CI=0.29-0.85, p<0.05, I2=0%). However, there was no significant difference in amputation, MACEs, all-cause mortality, and major bleeding complications. Subgroup analysis showed that cilostazol treatment in patients with femoropopliteal drug-eluting stents (DES) implantation remained associated with higher primary patency and a lower risk of ISR. After EVT of femoropopliteal artery lesions, additional oral cilostazol enhances primary patency, reduces the occurrences of ISR and vessel re-occlusion, diminishes the risks associated with MALEs, lowers the need for repeat revascularization, and increases freedom from TLR rates. However, it does not impact amputation, MACEs, all-cause mortality, or major bleeding complications. These findings suggest cilostazol as a potentially safe and effective adjunct therapy in patients with femoropopliteal PAD after EVT. After undergoing endovascular therapy (EVT) for femoropopliteal artery lesions, the addition of cilostazol to antiplatelet therapy can significantly improve primary patency, reducing the incidence of in-stent restenosis, repeat revascularization, vessel re-occlusion, and major adverse limb events while increasing freedom from target lesion revascularization rate. The simultaneous use of drug-eluting stents in the femoropopliteal artery lesions, combined with cilostazol, potentially results in a synergistic anti-stenotic effect. This therapeutic approach does not appear to be associated with an increased risk of major bleeding events or all-cause mortality. These findings provide additional evidence supporting the treatment of anti-stenosis in patients with femoropopliteal artery lesions after EVT.

Comparison of mid-outcome among bare metal stent, atherectomy with or without drug-coated balloon angioplasty for femoropopliteal arterial occlusion.

This study evaluated the outcomes of a bare metal stent (BMS), DCB alone, atherectomy plus a drug-coated balloon (AT + DCB) and AT alone for the treatment of femoropopliteal artery occlusion. Four groups were included in this retrospective cohort study: 119 patients underwent the BMS procedure, 89 patients underwent DCB alone, 52 patients underwent AT + DCB, and 61 patients underwent AT alone. Patients were followed-up at 1, 6, 12 and 24months after the procedure, the clinical outcomes and complications were assessed, and the primary outcomes were primary patency and restenosis. AT + DCB showed a lower bailout stent, and BMS displayed a higher retrograde puncture, flow-limiting dissection and postdilation (p < 0.05). For all procedures, the walking distance, ABI and pain score post-procedure were significantly improved compared with the pre-procedure values (p < 0.001). The restenosis rate was higher in BMS (21.0%) and AT alone (24.6%) than in DCB (10.1%) alone and AT + DCB (11.5%) (p = 0.04); there was no difference in amputation or clinically driven target lesion revascularization among procedures. The primary patency rates were 77.7%, 89.4%, 88.0% and 73.7% in the BMS, DCB alone, AT + DCB and AT alone groups at 24months, respectively (p = 0.03), while the secondary patency and main adverse events (stroke, MI and death) were similar. Proximal concavity, proximal target vessel diameter ≥ 5mm, runoff number ≥ 2 and DCB use were protective factors for primary patency. Our results suggested that AT + DCB and DCB alone were associated with higher primary patency, and DCB devices (combined with/without AT) should be the preferred choice for FP lesions.

Effect of hyperbaric oxygen treatment on diabetic foot ulcers: A meta-analysis.

The meta-analysis aimed to assess the effect of hyperbaric oxygen treatment on diabetic foot ulcers. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 17 examinations from 1992 to 2022 were enrolled for the present meta-analysis, including 7219 people with diabetic foot ulcers. Hyperbaric oxygen treatment had a significantly higher healed ulcer (OR, 14.39; 95% CI, 4.02-51.52, p < 0.001), higher adverse event (OR, 2.14; 95% CI, 1.11-4.11, p = 0.02), lower mortality (OR, 0.22; 95% CI, 0.07-0.71, p = 0.01) and higher ulcer area reduction (MD, 23.39; 95% CI, 11.79-34.99, p < 0.001) compared to standard treatment in patients with diabetic foot ulcers. However, hyperbaric oxygen treatment and standard treatment had no significant difference in amputation (OR, 0.62; 95% CI, 0.22-1.75, p = 0.37), major amputation (OR, 0.59; 95% CI, 0.18-1.92, p = 0.38), minor amputation (OR, 0.64; 95% CI, 0.15-2.66, p = 0.54) and healing time (MD, -0.001; 95% CI, -0.76 to 0.75, p = 0.99) in patients with diabetic foot ulcers. The examined data revealed that hyperbaric oxygen treatment had a significantly higher healed ulcer, adverse event, and ulcer area reduction and lower mortality, however, there was no significant difference in amputation and healing time compared to standard treatment in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size and some of the comparisons had a low number of selected studies.

Jetstream Atherectomy with Paclitaxel-Coated Balloons: Two-Year Outcome of the Prospective Randomized JET-RANGER Study.

The JET-RANGER study (NCT03206762) was a multicenter (11 US centers) randomized trial, core lab adjudicated, designed to demonstrate the superiority of Jetstream + Paclitaxel coated balloon (JET+PCB) versus angioplasty (PTA) + PCB in treating femoropopliteal (FP) arterial disease. The one-year primary endpoint of JET-RANGER has been recently published. The 2-year outcome data are presented in this report. There were 43 patients who completed the 1-year follow-up. Two were lost to follow-up and one died prior to the 2-year follow-up, resulting in 40 patients. Fifteen patients were randomized to PTA+PCB and 25 patients to JET +PCB. Kaplan Meier Survival analysis was performed to estimate the freedom from TLR. Bailout stenting was not considered a TLR in this analysis. Statistical significance was determined by a p-value < 0.05. Freedom from TLR was similar between the 2 groups at 2 years. There was also no significant difference in the change of ABI between the PTA + PCB and JET + PCB from baseline at 6-months, (p-value = 0.7890), 1-year (p-value = 0.4070), and 2-year (p-value=0.7410). There was also no statistical difference between the JET + PCB and PTA + PCB arms for RCC improvement by one or more category, (p-value= 1.000). There were no minor or major amputations for either arm throughout the 2-year follow up. One JET + PCB patient died before the 2-year specified window. JET + PCB had similar freedom from TLR and improvement in ABI and RCC at 2-year follow-up when compared to PTA + PCB with no difference in amputation or mortality between the 2 arms. NCT03206762.

Analysis of Concomitant and Isolated Venous Injury in Military Lower Extremity Trauma

The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. The Fasciotomy and Vascular Injury Outcomes database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004 and 2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAIs) and concomitant arteriovenous injuries (AVIs). In limbs with any venous injury, outcomes were compared between those undergoing venous repair and venous ligation. Three hundred thirty patients (133 IAIs, 135 AVIs, 62 isolated venous injuries [IVIs]) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, P=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, P=0.01), and multilevel vascular injury (6.7% vs. 0.8%, P=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, P=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, P=0.21) or amputation rate (25.9% vs. 18.8%, P=0.16) were present, though the limb deep venous thrombosis rate was 12.6% in AVIs versus 7.5% in IAIs (P=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, P=0.23) or limb complication rates (71.8% vs. 72.3%, P=0.94). Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.

Analysis Of Concomitant And Isolated Venous Injury In Military Lower Extremity Trauma

OBJECTIVES The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. METHODS The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). RESULTS 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries-IVI) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). CONCLUSION Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes. The implications of major venous injury to the lower extremity are not well established. We aimed to determine the significance of concomitant and isolated femoropopliteal venous injury and assess the impact of surgical management strategies on limb outcomes. The Fasciotomy and Vascular Injury Outcomes Database was queried for limbs sustaining femoropopliteal arterial, venous, or concomitant injuries in Iraq or Afghanistan between 2004-2012. Demographics, injury patterns and severity, interventions, and outcomes were compared between patients sustaining isolated arterial injuries (IAI) and concomitant arteriovenous injuries (AVI). In limbs with any venous injury, outcomes were compared between those undergoing venous (VR) and ligation (VL). 330 patients (133 IAI, 135 AVI, 62 isolated venous injuries-IVI) were included. AVI was associated with greater limb injury severity: median extremity Abbreviated Injury Scale (AVI 4 vs. IAI 3, p=0.01), Mangled Extremity Severity Score >7 (25.9% vs. 13.5%, p= 0.01), multi-level vascular injury (6.7% vs. 0.8%, p=0.01) and with greater fasciotomy use (83.0% vs. 69.2%, p=0.01). No differences were present in tourniquet use/time, shunting, or nature of arterial repair. No differences in vascular or limb complications (71.1% vs. 63.9%, p=0.21) or amputation rate (25.9% vs. 18.8%, p=0.16) were present, though limb DVT rate was 12.6% in AVI vs. 7.5% in IAI (p=0.17). Limbs with IVI had a 12.9% amputation and a 74.2% complication rate. Repair (n=103) versus ligation (n=94) of venous injuries was not associated with a difference in amputation (18.4% vs. 25.5%, p=0.23) or limb complication rates (71.8% vs. 72.3%, p=0.94). Despite higher extremity injury severity and more frequent fasciotomies, concomitant venous injury was not associated with poorer limb salvage or complications. With nontrivial amputation and complication rates, IVI is indicative of severe limb trauma. Repair of femoropopliteal venous injuries does not appear to influence limb outcomes.

Endovascular or open surgical treatment of high-risk patients with infrainguinal peripheral arterial disease and critical limb ischemia.

Aim To determine preferable type of treatment in our clinical circumstances by following two groups of patients with critical limb ischemia (CLI), who were treated endovascularly and surgically. Methods Research was carried out in the form of a prospective study of 80 patients with CLI and Trans-Atlantic Inter-Society Consensus (TASC) C or D type of arterial disease, with American Society of Anesthesiology (ASA) class III risk, who were randomly divided in two groups as per the treatment they received, surgical and endovascular. Patients were followed during 28 months using clinical examination and Duplex Ultrasound (DUS) in accordance with prescheduled control visits. Results There was a statistical difference between surgical and endovascular group in two years patency (82.5% vs. 55%; p=0.022) but it did not result in the difference in amputation free survival (AFS) (95% vs. 85%; p=0.171) or two-year freedom from major adverse limb events (MALE) (87.5 vs. 77.5; p=0.254). Also, there was no difference in the overall survival of patients (100% vs. 97.5%; p=0.317). Conclusion Initial endovascular treatment is a preferred form of the treatment for selected patient population.

Evaluating surgical outcomes in pediatric extremity vascular trauma

BackgroundThe purpose of this study was to evaluate the epidemiology and management of pediatric vascular extremity trauma to assess injury patterns and other factors that may contribute to poor outcomes. MethodsUsing the California Office of Statewide Health Planning and Development discharge database, we identified pediatric patients with extremity arterial trauma admitted to acute-care hospitals from 2007 to 2014. Demographics, management patterns, and outcomes were collected and analyzed. ResultsA total of 775 patients were treated for an extremity arterial injury. Overall, 40% were admitted to pediatric trauma centers and 39% to adult trauma centers. Management was predominantly by open surgical repair. Injury to the common femoral artery was associated with mortality (Hazard Ratio 3.9; 95% CI 1.1–14.5; p < 0.05). Popliteal artery injuries (Odds Ratio [OR] 4.8; 95% CI 1.2–19.9; p < 0.05) and anterior tibial artery injuries (OR 7.1; 95% CI 1.4–37.3; p < 0.05) had an increased risk of amputation. There was no difference in amputation or mortality rates by hospital category. ConclusionsPediatric extremity arterial injuries are rare. In California, outcomes are similar by hospital type. Common femoral artery injuries are associated with an increased risk of mortality, while popliteal and anterior tibial artery injuries are associated with an increased risk of amputation. Type of StudyPrognosis Study. Level of EvidenceLevel III.

Q&amp;A: Toe Amputation

QUESTION: Using the AMA Guides, Fifth Edition, how do I rate a laceration to the left foot that resulted in amputation of the third toe at the middle of the proximal phalanx along with some numbness to the next toe?ANSWER: In the AMA Guides, Fifth Edition, Chapter 17, The Lower Extremities, provides less detail on the assessment of amputation of phalanges than does Chapter 16, The Upper Extremities. However, the criteria listed in Chapter 17 and principles from Chapter 16 can be used to define impairment.Table 17-32, Impairment Estimates for Amputation (5th ed, 545) provides the following information:The first number is the whole person impairment, the second number in parentheses is the lower extremity impairment, and the third number in square parentheses is the foot impairment.If more than one toe is involved, by analogy to the Chapter 16 (page 443), the foot impairments for amputation of each involved toe are added at the foot level, converted to the lower extremity, and ultimately converted to the whole person.Different values are used for the great toe if amputation is at the MTP joint (17% foot impairment) or the interphalangeal (IP) joint (7% foot impairment). However, this degree of detail is not provided for the lesser toes.The great toe has a role in balance and gait (push off), and the lesser toes have little or no functional role in gait. The middle phalanx of toes 2–5 is very small, and the best analogy to an amputation through the IP of the great toe would be amputation through the proximal interphalangeal (PIP) joint of a lesser toe.With the great toe, the difference in amputation at the IP joint vs the MTP joint is 41% (7 foot/17 foot). The value halfway between the MTP joint and IP joint is 12% foot (midpoint between 7 and 17), this being 70% (12/17) of the value assigned to amputation at the MTP joint. Therefore, it would be reasonable to conclude that amputation at the PIP joint of the lesser toes would be 1% foot (41% of 3% foot). Amputation half way between the MTP and IP joint would still be 1% foot impairment. It would be reasonable to assign “3rd toe amputation at middle of proximal pha-lange” as 1% foot.It is difficult to quantify what the impairment would be for “some numbness to the next toe” after laceration. In assessing impairment of upper extremity digits, total sensory loss is assigned a value of 50% of the amputation value and partial sensory loss is assigned 25%, as noted in Table 16-5, Sensory Quality Impairment Classification (5th ed, 447). Partial sensory loss in the upper limb is loss associated with a known nerve injury and decreased sensation on physical exam. Partial sensory loss does not mean that “it feels odd when you touch me there,” but rather it is the inability to recognize touch (either monofilament stimuli not perceived at all or decreased 2 point discrimination). Therefore, using the description of “some numbness” and assuming an abnormal sensory exam, but no total anesthesia, it would be reasonable to assign a value of 25% of the amputation value. If one used the value at the MTP joint, this would be 1% (25% × 3% foot).The values of 1% foot for the amputation and 1% foot for sensory disturbance are combined, resulting in 2% foot impairment. This is converted to lower extremity by multiplying by 0.7, resulting in 1% lower extremity, which is equivalent to 0% whole person per Table 17-3 (5th ed, 527).If you had assigned the entire amputation value for the lesser toe, for example, 3% foot, and for the toe with sensory disturbance at 1.5% foot (50% of the 3% foot value for amputation), you would have 4.5% foot. This converts to 3% lower extremity, which is also equivalent to 1% whole person.You did not state the residual motion in the MTP joint of the third toe or of the adjacent lacerated toe. If MTP joint motion is abnormal, there may be additional impairment from Table 17-14 (page 537) of loss of motion or additional impairment for ankylosis from Table 17-30 (page 543).

Meta-Analysis of Drug-Eluting Balloon Angioplasty and Drug-Eluting Stent Placement for Infrainguinal Peripheral Arterial Disease

PurposeTo perform a meta-analysis of randomized controlled trials (RCTs) of drug-eluting balloon (DEB) angioplasty and drug-eluting stents (DESs) for infrainguinal peripheral arterial disease. Materials and MethodsSystematic searches were performed for all relevant RCTs. ResultsEight RCTs for DEB angioplasty and 12 RCTs for a DES in peripheral arterial disease were identified. Meta-analysis demonstrated statistically significant superiority of DEB over plain balloon angioplasty of femoral-popliteal disease for late lumen loss, restenosis, and target lesion revascularization, with no benefit in major amputation or mortality. Statistically significant superiority of DEB over percutaneous transluminal angioplasty (PTA) was demonstrated for infrapopliteal disease for restenosis and target lesion revascularization. Drug-eluting stents showed statistically significant superiority over bare metal stents (BMSs) of femoral-popliteal disease for late lumen loss and restenosis, with no benefit in mortality or amputation. Drug-eluting stents showed statistically significant superiority over BMSs of infrapopliteal disease restenosis and target lesion revascularization, with no benefit in amputation or mortality. ConclusionsDrug-eluting balloon angioplasty and DESs demonstrated superior outcomes compared to PTA and BMS, with no difference in amputation or mortality.

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)

AimsThe objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors. MethodsWe assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation±DFU and debridement, and no foot conditions. ResultsOverall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR=0.21; 95% CI: 0.10, 0.46) or DFU (OR=0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications. ConclusionIn managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.

A Six-Year Observational Study on Acute Limb Ischaemia in a Local Emergency Department in Hong Kong

Introduction Acute limb ischaemia is an important presentation to accident and emergency department (AED). This study aimed to find out the sensitivity of AED colleagues on diagnosing acute limb ischaemia and any association between delayed diagnosis and poor outcome. Prognostic factors that might be associated with amputation and mortality rates were also investigated. Methods This was a retrospective observational study of patients admitted to Kwong Wah Hospital with a diagnosis of acute limb ischaemia over a six-year period. The risk factors for acute limb ischaemia, the sensitivity of reaching the diagnosis at AED, and outcome in terms of amputation and 30-day mortality post-admission were assessed. Results The sensitivity of Kwong Wah Hospital AED in diagnosing acute limb ischaemia was 78.3%. Advanced age, lower limb involvement and history of aortic graft were associated with higher risk of mortality. Patients diagnosed and referred by other sources, e.g. private practitioner, were also associated with higher mortality. Male sex, smoking and intravenous drug abuse were associated with higher amputation rate. Atrial fibrillation seemed to be a protective factor against amputation. Delayed diagnosis group comprised 22% of the cases. There was no significant difference in amputation and mortality rates between the early diagnosis and delayed diagnosis groups. Conclusions AED physicians should always include acute limb ischaemia into the list of differential diagnoses. Further larger scale studies may be performed to investigate the impact of delay in diagnosis on outcome of patients.

Associated Venous Injury Significantly Complicates Presentation, Management, and Outcomes of Axillosubclavian Arterial Trauma

Axillosubclavian vessel injury (ASVI) is associated with high morbidity and mortality. Most studies are single-center experiences of small numbers of patients with penetrating injury. We assessed 21st-century presentation and management of ASVI and focused on outcomes of combined arterial/venous injury. We reviewed the National Trauma Data Bank for patients with isolated arterial ASVI (group 1) and combined arterial/venous ASVI (group 2). Demographics, injury severity parameters, interventions, complications, and outcomes were compared. We identified 581 patients with ASVI (mean age 35.1; 88.1% male), with 466 isolated arterial injuries and 115 combined arterial/venous injuries. Group 2 had lower presenting systolic blood pressure and Glasgow Coma Scale, and had higher rates of operative repair (55.7 vs. 43.1%, p = 0.016) and higher mortality (33.9 vs. 13.9%, p < 0.001). There were no differences in amputation (5.2 vs. 2.4%, p = 0.121), compartment syndrome (2.6 vs. 1.9%, p = 0.713), and deep vein thrombosis (0.9 vs. 0.2%, p = 0.357). When separated by mechanism of injury, combined injuries from blunt trauma did increase amputation rates (27.8 vs. 4.2%, p = 0.002). Multivariate analysis revealed that combined arterial/venous injury significantly increased risk of death (odds ratio [OR], 2.99; confidence interval [CI], 1.73 to 5.17; p = 0.0001). Penetrating injury had higher odds of death than blunt injury (OR, 1.96; CI, 1.03 to 3.73; p = 0.041). ASVI is rare but extremely lethal. Concomitant venous and arterial injury is not associated with worse limb-related outcomes, except in blunt injuries and resultant amputations, but is associated with a threefold increase in mortality rates compared with isolated arterial injury.

Ethnicity and risk of diabetes-related lower extremity amputation: a population-based, case-control study of African Caribbeans and Europeans in the United kingdom.

In the United States, people of black African descent with diabetes have 2 to 3 times the amputation risk of whites. This may be due to differences in care or pathophysiological characteristics. We therefore determined diabetes-related amputation rates in African Caribbeans vs Europeans in the United Kingdom, where care delivery is more equitable. We conducted an incidence and case-control study, based in London, England. All diabetes-related amputations performed between 1992 and 1997 were identified. Controls, those with diabetes but no amputation, were sampled from family practitioners. Risk factor data were abstracted from medical records. Incident diabetes-related amputation occurred in 67 Europeans and 19 African Caribbeans. Amputation rates, age standardized to the diabetic population, were 147 per 100 000 and 219 per 100 000 in African Caribbeans and Europeans, respectively (relative risk, 0.67; 95% confidence interval [CI], 0.32-1.40; P =.2). Case-control analyses were performed on 178 cases and 350 controls. The ethnic difference in amputation risk differed significantly by sex (P =.009 for interaction). The unadjusted odds ratio comparing African Caribbeans with Europeans in men was 0.31 (95% CI, 0.17-0.57; P<.001), and in women was 0.97 (95% CI, 0.49-1.85; P =.9). Adjustment for smoking attenuated the odds ratio in men to 0.45 (95% CI, 0.23-0.89, P =.02); adding neuropathy, peripheral vascular disease, and age attenuated the odds ratio further to 0.97 (95% CI, 0.34-2.73; P =.9). In contrast to the United States, we find no ethnic difference in diabetes-related amputation in women in the United Kingdom, but in men, amputation risk in African Caribbeans is one third that of Europeans. This was wholly accounted for by low smoking, neuropathy, and peripheral vascular disease rates.