Elective Reconstruction Research Articles

P2-16-05: Delay of Adjuvant Chemotherapy after Elective Mastectomy and Immediate Reconstruction in Breast Conservation Candidates: A Matched-Pair Analysis.

Abstract Background: To analyze factors that influence the timing of adjuvant chemotherapy in patients who are candidates for breast conservation therapy (BCT) but elect mastectomy with immediate reconstruction (M-IR). Methods: Using data from the University of Louisville Cancer Registry, we identified 35 consecutively-treated patients with stage I or II breast cancer between 2004 and 2009 who underwent M-IR and adjuvant chemotherapy. These were matched for age and AJCC stage to 35 controls who underwent BCT and adjuvant chemotherapy. We examined the timing of initiation of chemotherapy from the date of surgery and assessed the probability of therapeutic delay using univariate logistic regression and McNemar's test for matched pairs. Results: For the 70 patients included in this study, the median age was 46y (range: 30–65y), and the distribution for stage I, IIA and IIB was 22.9%, 65.7% and 11.4%, respectively. The two groups were well balanced in terms of race, rural/urban status, smoking, diabetes, insurance coverage, and histology. The median time to initiation of adjuvant chemotherapy was 38 days (range: 25–103 days) for BCT and 55 days (range: 30–165 days) for M-IR. Patients undergoing M-IR were more likely to experience any delay (> 45 days; 74.3% vs. 25.7%, p < 0.001) and/or significant delay (>90 days; 20.0% vs. 2.9%, p < 0.001) than those choosing BCT. On univariate logistic regression analysis, the extent of surgery had a major impact on the likelihood of any delay in chemotherapy (OR= 8.35, 95% C.I. = 2.86−24.3, p <0.001). None of the other aforementioned factors predicted for delay. Conclusion: The use of elective mastectomy with immediate reconstruction in breast conservation candidates independently predicts for delay in initiation of adjuvant chemotherapy. Further study is needed to qualify the underlying causes of and ultimate clinical significance of these delays. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-05.

Surgical Management of Symptoms and Aesthetic Sequels of a Spontaneously Resolved Vulvar Hemangioma

Introduction: A spontaneously resolved vulvar hemangioma can cause clinical symptoms and aesthetic deformities. Reduction and reconstruction of the affected labia majora can restore gross and functional anatomy and offers an opportunity to gain greater insight into the emotional and physical effects of labial problems. This report shares a unique case in which an elective reduction and reconstruction of the left labium majus were performed on a 16-year-old young woman. Materials and Methods: Surgical reduction and reconstruction were performed under general anesthesia. Prophylactic intravenous antibiotics were provided 30 minutes before surgical intervention. Results: Restoration of gross and functional anatomy was achieved with satisfactory aesthetic results. There were no intraoperative, short-term, or long-term complications. Minimal blood loss was recorded. Postoperative course and recovery were uneventful. The patient was satisfied on multiple levels. Her body image and daily quality of life were mar...

Surgical Management of Symptoms and Aesthetic Sequels of a Spontaneously Resolved Vulvar Hemangioma

Introduction: A spontaneously resolved vulvar hemangioma can cause clinical symptoms and aesthetic deformities. Reduction and reconstruction of the affected labia majora can restore gross and functional anatomy and offers an opportunity to gain greater insight into the emotional and physical effects of labial problems. This report shares a unique case in which an elective reduction and reconstruction of the left labium majus were performed on a 16-year-old young woman. Materials and Methods: Surgical reduction and reconstruction were performed under general anesthesia. Prophylactic intravenous antibiotics were provided 30 minutes before surgical intervention. Results: Restoration of gross and functional anatomy was achieved with satisfactory aesthetic results. There were no intraoperative, short-term, or long-term complications. Minimal blood loss was recorded. Postoperative course and recovery were uneventful. The patient was satisfied on multiple levels. Her body image and daily quality of life were markedly improved. Conclusions: In this case, reduction and reconstruction of the labium majus for a spontaneously resolved hemangioma were well-tolerated, and complications were not observed. A satisfactory restoration of gross and functional anatomy resolved clinical symptoms and improved aesthetic appearance. It also helped alleviate the patient's emotional and body-image concerns.

Secondary extremity reconstruction with free perforator flaps for aesthetic purposes

Perforator flap surgery enables surgeons to tailor flaps to individual requirements with reduced donor-site morbidity. The technique allows better aesthetic results to be achieved in various fields of microsurgical reconstruction, but reports on aesthetic resurfacing and contour restoration of extremity deformities are sparse. The authors present their experience of elective reconstructions of established deformities in the extremities for aesthetic purposes using free perforator flaps. Aesthetic results were evaluated using a questionnaire and by photographic grading. From March 2006 to June 2010, 15 free flaps were transferred in 14 patients for aesthetic purposes to restore established skin and soft-tissue deformities in the extremities. Twelve flaps were transferred to lower extremities and three to upper extremities. After recreating tissue deficiencies, flaps were precisely designed and elevated with elaborate flap insetting and thickness control. Patient-assessment questionnaires were administered after surgery, and aesthetic results were evaluated using photographs by independent observers. Photographic gradings were assessed statistically using the generalised estimating equation. Eight deep inferior epigastric artery perforator free flaps and seven thoracodorsal artery perforator free flaps were used in the 14 patients. Flap sizes ranged from 8 × 14 to 14 × 38 cm, and all flaps survived well. The patient satisfaction rate was high, and aesthetic improvements were confirmed by conducting objective photographic evaluations. Statistically significant changes were detected during the photographic evaluation (p < 0.05). Secondary reconstruction using a customised free perforator flap to achieve aesthetic improvements is a valuable option for the restoration of established skin and soft-tissue deformities in the extremities.

Deepithelialized reverse pedicled forearm flap: a technical modification useful in hand and wrist reconstruction

Reverse pedicled forearm flap is a reliable and easy option for hand and wrist reconstruction. Between 2000 and 2009, eight patients underwent elective reconstruction of an upper extremity using a pedicled reverse radial forearm flap with a modified technique; a retrospective chart review of the results is presented. The surgically modified procedure is described. The flap donor area is deepithelialized with a dermatome and the split-thickness skin graft obtained is left on the donor site pedicled proximally; the deepithelialized flap is then elevated and rotated with the standard technique and the forearm donor site is covered by repositioning and suturing the skin previously harvested with the dermatome. This useful and easy technical modification allows prevention of post-operative pain and long-term dyschromia in the split-thickness skin graft donor site, making the reverse pedicled forearm flap an even better option in hand and wrist reconstruction.

Comparison of retroperitoneal and transperitoneal approach for reconstruction of abdominal aortic aneurysm in patients with previous laparotomy

Although the standard surgical approach for repair of infrarenal abdominal aortic aneurysm (AAA) has been the transperitoneal approach, several reports have suggested the usefulness of retroperitoneal aortic reconstruction. However, the superiority of the retroperitoneal compared with transperitoneal approach is still controversial. To compare the efficacy of the retroperitoneal with that of the transperitoneal approach in elective AAA resection, 19 consecutive cases with previous laparotomies were randomly reviewed. From January 1990 through December 1992, 94 consecutive patients underwent elective reconstructions of an infrarenal AAA. Among them, 75 patients had had no previous surgery of any kind. In all of them, the transperitoneal approach was used (Group I). Nineteen other patients who had various laparotomies were randomly divided into two groups. The transperitoneal approach was used in 10 patients (Group II), and the retroperitoneal approach was used in 9 patients (Group III). Thus, the patients were separated into three groups and the intra- and postoperative parameters were compared. Surgical data including operative time, intraoperative blood loss, and aortic cross-clamping time did not differ significantly between the transperitoneal approach in the patients without laparotomy (Group I) and the retroperitoneal approach (Group II). In addition, the postoperative recovery including the initiation of alimentation and postoperative hospitalization also did not differ significantly between the two groups. However, there was a significant difference in the operative time and the blood loss between the retroperitoneal approach (Group II) and transperitoneal approach (Group III) in the patients with previous laparotomy. In addition, the postoperative parameters including the initiation of oral intake was sooner and hospitalization was significantly shorter in the retroperitoneal group (Group II) than in the transperitoneal group (Group III) with previous laparotomy. There was no incidence of postoperative adhesive ileus in the patients with the retroperitoneal approach (Group II). The results demonstrated no important advantage for the retroperitoneal approach compared with routine transperitoneal approach in the patients without previous laparotomy. However, in the patients with previous laparotomies, the retroperitoneal approach is a preferable alternative to the transperitoneal route.

The internal iliac arteries do not supply the inferior mesenteric artery

Ischemic colitis can be prevented after surgical treatment for abdominal aortic aneurysm by routine or elective reconstruction of the inferior mesenteric artery (IMA) when this vessel is patent. Revascularization of at least one internal iliac artery (IIA) has been recommended when the IMA is occluded, although the validity of such reconstruction has never been substantiated. This study investigated the role of the IIAs in IMA hemodynamics: Do IIAs contribute significant collateral blood supply to the IMA bed in the treatment of abdominal aortic aneurysms? Between July 1990 and June 1992, 100 patients underwent elective aneurysmectomy. At least one IIA was routinely reconstructed whenever possible; 24 patients had 27 IIA revascularizations. When the IMA was patent (49 cases), the residual pressure in the inferior mesenteric artery (IMA stump pressure) and the pressure in the radial artery were measured before and during temporary occlusion of the IIAs. The inferior mesenteric indices (P) defined by the ratio of the IMA stump pressure (PIMA) to the pressure in the radial artery (PRAD) were calculated before (P1) and during (P2) clamping of the IIAs. The mean value of P1 was 0.64±0.03 versus 0.63±0.03 for P2 (P=NS). Adjustment of variations in P1 as a function of P2 by linear regression gave a straight line with a slope of less than 1. The IMA stump pressure is independent of whether vascular continuity of the IIAs is restored or whether these vessels are excluded. The IIAs do not contribute significant collateral blood supply to the IMA bed in treatment of abdominal aortic aneurysms.

Comparing the Cost‐Effectiveness of Short Orthopedic Missions in Elective and Relief Situations in Developing Countries

BackgroundThe earthquake that occurred in Haiti on 12 January 2010 elicited an unprecedented response from the American orthopedic community. Many small organizations, such as Operation Rainbow, were thrust into the unfamiliar environment of relief surgery, whereas they normally provide short elective reconstruction missions in developing countries.MaterialsBecause of the chaotic nature of relief work, it was assumed that the organization’s efforts would be less cost-effective than their usual elective work. To evaluate this conclusion, the present study was designed to compare the cost-effectiveness of the organization’s usual elective missions with the emergency relief provided in the wake of the Haiti earthquake.Results and conclusionsThe assumption that emergency costs would be higher was proven wrong, with estimates of $362 per disability-adjusted life-year (DALY) averted in the elective group, and $343 per DALY averted in the relief group.

Morbidity and mortality in the early postoperative course following elective reconstruction of abdominal aorta aneurysm using endovascular and open surgical techniques

Surgical treatment is the only method of abdominal aorta aneurysm (AAA) treatment. According to data of the available literature, elective open, i.e., conservative, reconstruction (OR) is followed by 3%-5% mortality, as well as by numerous comorbide conditions inside the early postoperative course (the first 30 days after the surgery) that occur in 20%-30% of the operated on. The aim of the study was to present preliminar results of a comparative clinical retrospective study of early postoperative morbidity and mortality in AAA reconstruction using endovascular (EVAR) and open surgical techniques. This comparative clinical retrospective study included 59 patients, electively operated on for AAA within the period January 2008-March 2009, divided into two groups. The group I counted 29 (49%) of the patients who had been submitted to EVAR by the use of Excluder stent. The group II consisted of 30 (51%) of the patients operated on using OR. All of the patients were males, 50-87 years old (mean 67.6 year in the group I, and 54-86 years (mean 68.3 years) in the group II. All tha patients had AAA larger than 50 mm, in the group I 50-105 mm (mean 68 mm), and in the group II 50-84 mm (mean 65 mm). Preoperative comorbide conditions of any patients were similar (coronary disease, obstructive lung disease, chronical renal insufficiency). Patients operated on as emergency cases due to rupture or due to symptomatic aneurysm (threthening rupture) were excluded. The analysed parameters were the duration of surgical operation, intraoperative and operative blood substitution, postoperative morbidity, the duration of postoperative hospitalization, and hospital mortality. The obtained results showed a statistically significantly shorter time taken by EVAR surgery (average 95 min, ranging 70-180 min) as compared to OR surgery (average 167 min, ranging 90-300 min). They also showed statistically significantly less blood loss in the patients operated on by the use of EVAR surgery (average blood compensation 130 mL, ranging 0-1050 mL) as compared to OR surgery (average blood compensation 570 mL, ranging 0-2.000 mL). Also, general complications as wound infection, no restoration of intestines peristalsis, febrility, proteinic and electolytic disbalance, lung and heart decompensation were statistically significantly less following EVAR than OR surgery. Postoperative hospitalization was also statistically significantly shorter after EVAR than after OR surgery (average 4.2 days, ranging 3-7 days; 10.6 days, ranging 8-35 days, respectively). Finally, within this 13-month study there was no mortality following EVAR surgery, while two patients died after OR surgery. In the patients with elective AAA reconstruction endovascular reconstruction is shown to be far more safer and minimally invasive procedure than open conventional aorta reconstruction.

Surgical blood loss during femoral rodding in children with osteogenesis imperfecta

Historically, patients with osteogenesis imperfecta (OI) have been reported to be at risk for significant surgical bleeding secondary to abnormalities in platelet function. By reviewing the operative blood loss in OI patients undergoing femoral osteotomies and rodding, we hoped to identify risk factors for excessive bleeding. A retrospective review of 22 patients with 52 inserted femoral rods was conducted under Institutional Review Board approval. Information concerning patients and procedures was collected. Associations with mean blood loss were made for categorical variables using the unpaired t-test and for continuous variables using correlation. Multivariate linear regression was used to test the influence of potential risk factors for excessive bleeding. The mean blood loss was 197 cc (standard deviation [SD] 129 cc, range 10-500 cc). The adjusted mean blood loss (ratio of actual blood loss divided by the total predicted blood volume [Custer and Rau in "The Harriet Lane Handbook," 18th edn. Mosby-Elsevier, Philadelphia, p 382, 2009]) was 0.16 (SD 0.13, range 0.01-0.44). Six blood transfusions were required out of 42 cases for a transfusion rate of 14%. The mean blood loss in those patients who were transfused was 279 cc compared with 182 cc for those not transfused. There were no differences in the adjusted mean blood loss between acute fracture treatment versus elective reconstruction (P = 0.08), nor between primary rodding versus revision rodding (P = 0.66). Older patients tended to have lower adjusted mean blood loss, though this was not significant (P = 0.07). Increasing number of osteotomies tended to lead to increased adjusted mean blood loss (P = 0.05). There was no association between operative time and adjusted mean blood loss (P = 0.36). When adjusting for procedure characteristics, increasing age was associated with decreasing adjusted mean blood loss (P = 0.008). Predicting blood loss for femoral rodding in patients with OI is difficult, with no differences between revision and primary procedures or elective versus trauma cases. The blood loss in our patients undergoing femoral rodding was manageable, and the transfusion rate was reasonably low. Although massive blood loss has been described in patients with OI in the literature, we found that femoral rodding did not pose excessive risk of transfusion in our OI population.

Invited Commentary

We very much appreciate the opportunity to analyze the manuscript by Zipfel and colleagues [1]. They have stated that prophylactic subclavian artery revascularization may reduce significant neurologic complications. They concluded that prophylactic reconstruction of subclavian artery is safer than later elective reconstruction after stent graft repair of thoracic aorta disease. However, the authors demonstrated no statistical difference in neurologic complications between the patients in the protected and unprotected series.

Spontaneous hemothorax during general anesthesia

We report a case of spontaneous hemothorax in a healthy 27-year-old man undergoing elective reconstruction of the right anterior cruciate ligament (ACL) under general anesthesia. In the postanesthesia care unit (PACU), the patient became hypotensive and tachycardic with mid-sternal chest discomfort. A chest roentgenogram revealed an almost complete opacification of the right hemithorax. A diagnostic thoracentesis was positive for frank blood, confirming a right hemothorax. The patient was emergently taken back to the operating room. A chest tube was inserted, and 3.3 l of dark blood was drained. Once the patient improved hemodynamically, we proceeded with a right video-assisted thoracoscopic surgery (VATS). A bleeding vessel incorporated in a bleb was identified at the apex of the right lung. The bleeding vessel was clipped. A wedge resection of the apical bleb was performed and the associated torn vascular adhesion was stapled. The patient was found to have bullous disease at the apical region of the right lung. These bullae can undergo neovascularization and form vascularized bullae. Rupture of these vascularized bullae can cause a spontaneous hemopneumothorax. In our patient it is possible that an apical vascularized bulla ruptured causing a massive intrapleural bleed.

Saphenous vein grafts for perforator flap salvage in autologous breast reconstruction

Although the use of saphenous vein grafts in free-flap salvage and extremity replantation is relatively common, their use in breast reconstruction is rare. These two case reports represent extreme alternatives for breast reconstruction flap salvage. In our normal daily practice, the overwhelming majority of elective breast reconstructions proceed smoothly. However, the occasional patient may require saphenous vein graft flap rescue for completion of the reconstruction.

Coated Prostheses Are Associated With Prolonged Inflammation in Aortic Surgery: A Cost Analysis

This prospective study was conducted to compare inflammatory responses between patients receiving coated and uncoated vascular prostheses, and to examine their effect on length of stay and cost of patients undergoing abdominal aortic aneurysmectomy. Patients undergoing elective vascular reconstruction of an abdominal aortic aneurysm were assigned randomly to coated-graft or uncoated-graft groups (n = 20, for each group). Interleukin (IL)-6, granulocyte elastase, white blood cell count, C-reactive protein (CRP), and body temperature (BT) were prospectively recorded preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. In-hospital stay and hospitalized costs were also analyzed. IL-6 and CRP concentrations in the coated-graft group were higher than those in the uncoated-graft group (P = 0.01 and 0.05). BT was more frequently elevated >37 degrees C at POD 14 in the coated-graft group than in the uncoated-graft group (P =0.03). Discharge was delayed, and overall hospitalization cost was higher in the coated-graft group than in the uncoated group (17.6 vs. 13.5 days, and 2 010 000 vs. 1 780 000 yen, P = 0.006 and P = 0.002, respectively). Coated vascular prosthesis demonstrated more profound inflammatory reaction than noncoated prosthesis, postoperatively.

Venous Thrombosis in Coupled Versus Sutured Microvascular Anastomoses

The anastomotic coupling device (ACD) is currently used for microsurgical venous anastomoses as an alternative to sutures and can reduce anastomotic time. We reviewed the microsurgical procedures performed at the University of Texas M. D. Anderson Cancer Center over a 40-month period. Procedures were performed for elective reconstruction of the breast, head or neck, or extremities after tumor excision. Thrombosis and ultimate flap salvage rates were compared between cases using ACDs and those using sutures for the venous anastomoses. Seven hundred twenty-three free flaps were included in the study. There were no intraoperative technical complications using the ACD. Overall, the venous thrombosis rates were not significantly different between the ACD (1.4%, 2/139 cases) and sutured (3.3%, 19/584 cases) groups. Salvage rates following venous thrombosis were not significantly different for venous anastomoses performed with an ACD (50%, 1 of 2 cases salvaged) compared with venous anastomoses performed with sutures (68.4%, 13 of 19 cases salvaged). The ACD is a useful alternative to sutured venous anastomoses that can reduce anastomotic time while achieving similar patency rates.

Intraoperative Peripherally Inserted Central Venous Catheter Central Venous Pressure Monitoring in Abdominal Aortic Aneurysm Reconstruction

Numerous studies have found no clinically significant benefit to the perioperative use of pulmonary artery catheters (PACs), and peripherally inserted central venous catheters (PICCs) have been reported to measure central venous pressure (CVP) accurately. The objective of this study was to determine whether the dynamic shifts in preload associated with elective reconstruction of abdominal aortic aneurysms (AAAs) are accurately reflected by CVP measurements from open-ended PICCs compared to CVP measurements from concomitant indwelling PACs. This is a retrospective review of prospectively collected data. PICCs and PACs were placed preoperatively in five patients undergoing elective AAA reconstruction. CVP measurements were recorded every 15 min during the operation. Bland-Altman statistical analysis was used to determine the degree of agreement in data collected by the two measurement devices. Seventy-three paired measurements of CVP from concomitant indwelling PICCs and PACs obtained from five patients undergoing elective AAA reconstruction revealed PICC measurements to be higher than PAC measurements by 0.6 mm Hg (overall correlation coefficient 0.92). The difference between the two measurement devices was expected to be <3.4 mm Hg at least 95% of the time. The findings of this pilot study indicate that PICCs are an effective method for CVP monitoring in situations of dynamic systemic compliance and preload, such as those observed during elective AAA reconstruction.

Preoperative Cardiac Evaluation Does Not Improve or Predict Perioperative or Late Survival in Asymptomatic Diabetic Patients Undergoing Elective Infrainguinal Arterial Reconstruction

Preoperative Cardiac Evaluation Does Not Improve or Predict Perioperative or Late Survival in Asymptomatic Diabetic Patients Undergoing Elective Infrainguinal Arterial Reconstruction

Conservative management of asymptomatic popliteal aneurysm

Historical review shows that the treatment of popliteal aneurysm has developed by trial and error and there is disagreement about the proper management of the symptomless patient. In 1981 a policy of conservative management for asymptomatic popliteal aneurysm was adopted in this unit. Since that time we have also managed nine patients with thrombosed popliteal aneurysms by arteriography and low-dose intra-arterial streptokinase. Six patients treated within 72 h of occlusion achieved significant (70-100 per cent) lysis, but streptokinase was ineffective in those treated 10 or more days after the thrombosis. Of the six patients with significant lysis, three were treated by elective reconstruction and two by anticoagulation. One patient who had significant lysis died. Vascular patency of all five successfully treated limbs was maintained and no limb loss occurred in those who presented late and failed to achieve significant lysis. These results reinforce the view that thrombolysis is the treatment of choice for thrombosed popliteal aneurysms. The low complication rate for asymptomatic popliteal aneurysms and the advent of safe, effective thrombolysis indicate that operation for symptomless popliteal aneurysm is no longer required.

Posttraumatic Thumb Reconstruction

After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction. The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient. A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer. Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction. The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient's posttraumatic function and specific reconstructive needs.

Preoperative Cardiac Evaluation Does not Improve or Predict Perioperative or Late Survival in Asymptomatic Diabetic Patients Undergoing Elective Infrainguinal Arterial Reconstruction

Preoperative Cardiac Evaluation Does not Improve or Predict Perioperative or Late Survival in Asymptomatic Diabetic Patients Undergoing Elective Infrainguinal Arterial Reconstruction