Ischemic Foot Research Articles

The impact of organized multidisciplinary care on limb salvage in patients with mild to moderate WIfI ischemia grades

The impact of organized multidisciplinary care on limb salvage in patients with mild to moderate WIfI ischemia grades

Comparative Study between Negative Pressure Wound Therapy (NPWT) and Standard Moist Wound Dressing (SMWD) In Management of Diabetic Non- Ischemic Foot Ulcers

Abstract Background Diabetic Foot Ulcer(DFU) is a common complication of diabetis that has shown an increasing trend over previous decades, 15% of patients with diabetes will suffer from DFU. and approximately 20% of hospital admissions among patients with DM are the result of DFU. Standard moist wound dressing (SMWD) is considered the traditional method for management of DFU. Supporting evidence for NPWT in the treatment of diabetic foot wounds include numerous prospective and multi-centered randomized controlled trials. Aim of the Work This study aimed to compare wound outcome, limb salvage between NPWT and SMWT in management of diabetic non ischemic foot ulcers. Patients and Methods This is a randomized controlled study involving 60 patients with active diabetic foot ulcers. A computer generated randomization pattern will be used to segregate the patients into 2 groups (NPWT and SMWD groups). Primary end point of the study is to achieve full healthy granulating wound (without necrotic tissues, bone or tendon exposure and without local signs of infection). follow up included change in wound diameter, depth, up or down scaling along UTWC, wound status every 2 weeks. Results there was a statistically significant difference in rate of depth improvement for the NPWT group in 2 and 4 weeks. In six weeks follow up, the rate of depth reduction was better in NPWT group but it wasn’t statistically significant (p-value 0.14). There was a statistically significant difference in reaching full healthy granulation in 4 and 6 weeks in favor of the NPWT group compared to the SMWD, there was no statistically significant difference in number of cases reaching full healthy granulation in 8 weeks as many cases of SMWD group started to achieve full healthy granulation. Number of bed side debridement or surgical debridement was not statistically significant between the 2 groups. major amputation was seen in 4 cases of the SMWD group, and one trans-metatarsal amputation and 2 toes amputation was seen in NPWT group and none of these was statistically significant. Conclusion NPWT use in DFU provides a significant reduction in duration till reaching full healthy granulation. No significant difference was observed in ulcer related complications such as infection, cellulitis, and osteomyelitis. However, the study showed that SMWD patients had more secondary amputations than those receiving NPWT but it wasn’t statistically significant

Comparative study between Negative Pressure Wound Therapy (NPWT) and Standard Moist Wound Dressing (SMWD) in management of diabetic non ischemic foot ulcers

Abstract Background and Aims Diabetes is rapidly increasing in prevalence worldwide and surgery in patients with diabetic foot is becoming more common. Foot complications are a major cause of admissions in diabetic patients, and comprise a disproportionately high number of hospital days because of multiple surgical procedures and prolonged length of stay in hospital. Diabetic foot is an umbrella term for foot problems in patients with diabetes mellitus. Foot disorders such as ulceration, infection and gangrene are the most common, complex and costly sequelae of diabetes mellitus. The optimal therapy for diabetic foot ulcers remains ill-defined. Saline-moistened gauze has been the standard method; however, it has been difficult to continuously maintain a moist wound environment with these dressings. This has led to the development of various hydrocolloid wound gels, which provided more consistent moisture retention. Refinements in topical ointments have resulted in the addition of various pharmacological agents including growth factors and enzymatic debridement compounds. Hyperbaric oxygen therapy and culture skin substitutes are other wound therapies that have been advocated. All these therapies are associated with significant expense and are being utilized in some situations without sufficient scientific evidence demonstrating their efficacy. Therefore, the search for an efficacious, convenient and cost-effective therapy continues. Negative Pressure Wound Therapy (NPWT) is a newer noninvasive adjunctive therapy system that uses controlled negative pressure using Vacuum-Assisted Closure device (VAC) to help promote wound healing by removing fluid from open wounds through a sealed dressing and tubing which is connected to a collection container. The use of sub-atmospheric pressure dressings, available commercially as a VAC device, has been shown to be an effective way to accelerate healing of various wounds. This was aimed to compare wound outcome, limb salvage, and cost effectiveness between Negative pressure wound therapy (NPWT) and Standard moist wound therapy (SMWT) in management of diabetic non ischemic foot ulcers. Methods we performed a cohort study involving 30 patients with active diabetic foot ulcers, in a high volume tertiary referral vascular center. They were divided into 2 groups: 15 patients (group A) were prescribed NPWT and the other 15 patients (group B) received SMWD. During follow up visits, progress of healing was evaluated and documented in the form of change in wound diameter, depth, up or down scaling along UTWC, wound status at 2, 4, 8, and 12 weeks and 4 weekly thereafter till complete epithelialization. Results As regard to ulcer depth there were statistically significant difference between the 2 groups during follow up duration of the study after 4 weeks with group A showing faster decrease in ulcer depth than group B denoting faster formation of granulation tissue. As regard to complete granulation of ulcer there were statistically significant difference between the 2 groups during follow up duration of the study markedly shown after 6 weeks with group A showing complete ulcer granulation faster than group B, with statistically significant difference as regard to number of days on dressing and follow up duration in weeks between the 2 groups with group A showing lesser number of days on dressing and shorter follow up duration in weeks than group B. Conclusion NPWT has a definitive role in promotion of proliferation of granulation tissue, reduction in the wound size, by and rapid clearing of bacterial load. Our data demonstrates that negative pressure wound dressings decrease the wound size more effectively than saline gauze dressings over the first 4 weeks of therapy. It is suggested that NPWT is a cost-effective, easy to use and patient-friendly method of treating diabetic foot ulcers which helps in early closure of wounds, preventing complications and hence promising a better outcome.

Use of Nevelia Dermal-Epidermal Regenerative Template in the Management of Ischemic Diabetic Foot Postsurgical Wounds.

The purpose of this cross-sectional study is evaluate the effectiveness of a dermal-epidermal substitute (DES) composed of 3-dimensional porous matrix of type 1, purified, stabilized, bovin-origin collagen (Nevelia, SYMATESE, Chaponost, France) without a subsequent skin graft in the treatment ischemic postsurgical diabetic foot ulcers. This study group was composed of a sample of consecutive diabetic patients with critical limb ischemia and postsurgical wounds. All patients received a preset limb salvage protocol including the application of the DES, but none received a skin graft. Patients were closely followed until wound healing or different outcome. The outcome measures were healing, nonhealing, major amputation, and death evaluated at 1 and 2 years of follow-up. Forty-one patients were included. The average postsurgical wound area was 69.6 ± 50 cm2. Twenty-one patients (51%) healed; 10 patients (24%) did not heal after 1 year of follow-up; however, all of them achieved a mean ulcer size reduction >50%; 7 patients (17%) were amputees; 3 patients (7.3%) died. In a later follow-up (2 years), wounds in 8 additional patients healed. Successful revascularization was an independent predictor of healing (hazard ratio = 5.1, 95% confidence interval [CI] = 2.5-14-9; P = .0001), the postsurgical ulcer size (>50 cm2) was an independent predictor of nonhealing (hazard ratio = 6.2, 95% CI = 2.1-38.4; P = .0001) while recurrence of critical limb ischemia was an independent predictor of major amputation (odds ratio = 3.4, 95% CI = 1.1-4.5; P = .002). The DES composed of type 1 bovin-origin collagen is useful in the treatment of large postsurgical diabetic foot ulcers, even when the skin graft is not a suitable therapeutic option.

Combination of active stage of diabetic Charcot neuroosteoarthropathy and diabetic lower limb macroangiopathy

Combination of active stage of diabetic Charcot neuroosteoarthropathy and diabetic lower limb macroangiopathy is the rare condition. In the present paper we describe two cases of development of acute Charcot foot in the non-critically ischemic foot. The first case is the patient with previously diagnosed intermitted claudication and the second case is patient who developed the Charcot foot 5 months later after successful endovascular treatment of arterial occlusions of his left lower limb. In both cases the absence of redness in the early stage, the mild-to-moderate pain and mild temperature gradient between affected and non-affected feet were noticed. The clinical course of the Charcot disease in the first patient was favourable. He used walker for 9 months and his foot shape was preserved and deformity was considered as mild. The second patient had more active and profound destructions due to delay of the treatment. He was casted, however his deformity progressed and the treatment continues up to date. In both patients the MRI revealed more affected bones compared with X-ray. These cases emphasize the importance of keeping in mind the Charcot disease even in patients with diabetic peripheral vascular disease.

The Controlling Nutritional Status Score is Significantly Associated with Complete Ulcer Healing in Patients with Critical Limb Ischemia

It has been reported that the Controlling Nutritional Status (CONUT) score, calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration, is a valuable nutritional status index. In the present study, we assessed whether the CONUT score was a significant predictor of complete ulcer healing in patients with critical limb ischemia (CLI). In this retrospective, single center, cohort study, conducted from January 2013 to June 2018, we treated 112 limbs of 89 patients with Fontaine 4 CLI at the Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Japan. The primary endpoint of the study was complete ulcer healing after revascularization, and the secondary endpoint was amputation-free survival (AFS). The mean follow-up time was 17.8months. Complete ulcer healing was achieved during the follow-up period in 91 (81.2%) limbs. The median ulcer healing time was 104days (range, 16-574days). In multivariate analysis, improvement of lower skin perfusion pressure ratio of <1, end-stage renal disease, and high CONUT score (>4) were predictive of incomplete ulcer healing in patients with Fontaine 4 CLI. In addition, the AFS rate was significantly better in patients with a CONUT score ≤4 than in those with a CONUT score >4. The CONUT score was associated with postprocedure ulcer healing and long-term limb retention in patients who underwent revascularization. The management of CLI involving ischemic foot ulcers may require ongoing consideration of nutritional status.

Topical NATROX® oxygen wound therapy on patients with ischemic foot ulcers – A case series

Background: The essential role of oxygen in wound healing is well documented, and recent developments in the delivery of topical oxygen therapy have made this a more viable treatment in practice. This article examines the role of topical oxygen – the NATROX® Oxygen Wound Therapy System in wound healing and looks at the impact of increased oxygenation on ulcer healing through a case series where the NATROX system was used in patients with ischemic foot ulcers. Materials and Methods: Topical oxygen therapy was evaluated in patients with ischemic foot ulcers in a tertiary referral specialist center. Results: During this case series of six patients, four patients had a complete healing before the study completion and two patients wounds were on a healing trajectory (average reduction in wound size of 60 %) during the follow-up, which eventually healed. Conclusion: NATROX® is an innovative topical oxygen delivery system that warranty further research to assess its potential impact on wound healing.

Ischemic diabetic foot ulcer when treated in association with photobiomodulation: Case report

Introduction: Because ischemic diabetic foot has arterial lesions with micro and macroangiopathies, it is challenging successfully treat ulcers even now. This becomes especially true if limb revascularization is impossible due to the particularities of systemic pathology and/or local arterial disease. Case Report: A 61-year-old male patient with type II Diabetes mellitus, arterial hypertension, chronic arterial insufficiency, single limb, with ischemic calcaneal ulcer and posterior tibial artery occlusion that irrigates the angiosome of the lesion, but unfavorable to revascularization. Defined by conventional treatment with platelet antiaggregant, statin and vasodilator associated with laser photobiomodulation (PBM). Red laser, 660 nm, 108 mW, 2.7 W/cm2, was used to irradiate the ulcer point by point, since the area of the laser beam was smaller than the area of the ulcer (laser beam = 0.04 cm2), in contact mode, 108 J/cm2, 4.32 J, and 10 s per point once a week for 33 weeks. Arterial Doppler ultrasound examinations were performed twice, i.e., after three and six months of treatment. Results: Gradual improvement of blood flow in the ulcer bed with postocclusive flow after three months, and after six months, triphasic flow toward the calcaneus. Conclusion: Photobiomodulation proved to be effective for the formation of collateral circulation in the occluded vascular bed studied here, despite only partial ulcer healing. Randomized controlled trials should be performed to better understand the effects of PBM.

Intraoperative Indocyanine Green Fluorescence Angiography during Minor Amputation of the Ischemic Foot

Intraoperative Indocyanine Green Fluorescence Angiography during Minor Amputation of the Ischemic Foot

Блеббинг плазматической мембраны лимфоцитов у пациентов с атеросклерозом магистральных артерий и ишемической формой синдрома диабетической стопы

Aim: to assess the blood flow state and the lymphocyte plasma membrane blebbing in atherosclerosis of the lower limb arteries and the ischemic diabetic foot (IDF).Patients and Methods: 75 patients (51 (68%) of them — women) underwent a prospective study with IDF and signs of chronic obliterating disease of lower limb arteries. In the majority of cases (92%), IDF occurred in the setting of type 2 diabetes mellitus. Blood circulation disorder corresponded to the stage II–III Fontaine–Pokrovsky classification, ulcerative defects — to the PEDIS grade 1–2 without signs of infection and with signs of local inflammation. The control group consisted of 25 healthy patients. Blood flow state (using Doppler ultrasound of the lower limb arteries) and diabetes mellitus compensation degree (by the level of glycated hemoglobin), as well as the lymphocyte membrane state were evaluated.Results: 72% of patients had a total occlusion of tibial and foot segments, 28% — stenosis. The level of glycated hemoglobin was 10.3 [8.5; 14.3]%, which indicated insufficient compensation of carbohydrate metabolism disorders. Total and terminal blebbing was 30.1 [25.4; 33.2]% and 15.8 [11.8; 18.4]%, which was 3 and 5 times higher than the control group, respectively. A high positive correlation was observed between the level of glycated hemoglobin and total (rS=0.72; p=0.001) and terminal (rS=0.78; p=0.001) lymphocyte membrane blebbing.Conclusion: given the presence of a high correlation between the indicator of glycated hemoglobin and lymphocyte plasma membrane blebbing, an increase in glycated hemoglobin can be used as a marker for the development of endothelial insufficiency in atherosclerosis of the lower limbs and IDF. At the same time, the level of total and terminal blebbing can be considered as a pathogenetic marker of macroangiopathy. KEYWORDS: diabetes mellitus, atherosclerosis, ischemia, hemodynamics, blebbing, glycated hemoglobin.FOR CITATION: Dunaevskaya S.S., Khachatryan A.T., Deulina V.V. Blebbing of plasma membrane of lymphocytes in patients with atherosclerosis of main arteries and ischemic form of diabetic foot syndrome. Russian Medical Inquiry. 2020;4(7):452–456. DOI: 10.32364/2587-6821-2020-4-7-452-456.

Outcomes of Infrainguinal Bypass Procedures in Diabetic Patients with Ischaemic Foot Ulcers: A Sri Lankan Experience in Limb Salvage

Outcomes of Infrainguinal Bypass Procedures in Diabetic Patients with Ischaemic Foot Ulcers: A Sri Lankan Experience in Limb Salvage

Indocyanine Green Fluorescence Imaging in Predicting Wound Healing After Limb Revascularization

Introduction - The most severe form of peripheral arterial disease is chronic limb threatening ischemia with tissue lesion. Assessment of critically ischemic foot is challenging.The conventional assessment methods are pressure measurements from ankle and toe level, ankle-brachial index (ABI) and transcutaneous oxygen pressure (TcPO2). Indocyanine green fluorescence imaging (ICG-FI) a relatively recent imaging method and still developing in many ways. The principle of ICG-FI is to illuminate the tissue of interest with light at the excitation wavelength (about 750 to 800nm) while observing it at longer emission wavelengths (over 800nm). ICG-FI gives a view of foot hemodynamic. After an intravenous injection of ICG, perfusion of the foot can be visualized with infrared camera and recorded for further analysis. Intensity of the fluorescence as a function of time can be analysed from the recorded images allowing a time-intensity curve to be drawn. We have earlier published analysis on the repeatability of ICG-FI and use of ICG-FI in immediate quality control after revascularization. In the current study we have analysed the use of ICG-FI in predicting wound healing after revascularization of CLTI and tissue lesion. Methods - Between January 2015 and February 2016 73 patients with CLTI and tissue lesion underwent either surgical (n=24) or endovascular (EVR) (n=49) revascularization. ICG-FI was done using Spy Elite before the revascularization, immediately after and during the follow-up. Maximum intensity, intensity rate and the relative change in the intensity rate were extracted from the automatic time intensity curve report. Results - During the mean follow-up of 16 months 77% of the wounds healed. 12 patients died and 9 had major amputation of the index leg. 4 mo, 6mo and overall wound healing rates were 51% and 63% respectively. The mean maximum intensity increased in the wound area from 92 (SD 61) AU to 132 (SD62) AU. The three parameters, change in maximum intensity, change in intensity rate and relative change in intensity rate were testes using ROC. The best area under curve was achieved with the absolute change in maximum intensity. 19AU increase predicted overall wound healing with 69% sensitivity and 68% specificity (AUC 0.79). 35 AU increase in intensity predicted wound healing in 4 months with 64% sensitivity and 63% specificity (AUC 0.68), 30 AU increase predicted wound healing in 6 months with 69% sensitivity and 69% specificity (AUC 0.72). In patients who underwent EVR the mean maximum intensity increased from 99.7 (SD 60.9) to 127.1 (SD 62.1) in the wound area. The corresponding increase in patients who underwent bypass was from 79.6 (SD60.1) AU to 140 (SD 62.9) AU (p<0.001). One-year wound healing rate after EVR was 84% and after bypass 92%. Conclusion - ICG-FI shows well the success of revascularization in individual patient. In our analysis the best parameter in predicting wound healing was absolute change in maximum intensity. The higher the change is achieved, the faster is the wound healing.

Quantitative Assessment of Indocyanine Green Angiography in the Follow-Up of Patients with Severe Chronic Limb Ischaemia

Introduction - An ischaemic wound heals slowly after revascularization, and repeated revascularizations are needed in many cases to avoid amputation. Therefore, a surveillance programme is recommended to ensure revascularization patency and to prevent the need for additional procedures using the ankle-brachial index (ABI) and the toes (TP). Indocyanine green fluorescence imaging (ICG-FI) is useful to evaluate the perfusion of an ischaemic foot. The aim of this study was to assess the feasibility of ICG-FI in the surveillance of patients who have undergone revascularization of severe chronic limb ischemia (SCLI). We sought to determine the sensitivity and specificity of ICG-FI in distinguishing possible revascularization failure after bypass or PTA, as compared to ABI and TP. Methods - In this prospective trial, 61 patients (62 limbs) with SCLI were examined with ABI, TP and ICG-FI at baseline, immediately after revascularization and at 3-month follow-up. Twenty-five patients (33%) underwent bypass, and 36 (67%) underwent a total of 37 PTAs. ICG-FI results were assessed with the SPY-Q software, which provides a time-intensity curve of the selected region of interest (ROI), showing the fluorescence intensity plotted against time in seconds. Three parameters were derived from the curve: maximum intensity, intensity rate (IU/S), and ICG10 (intensity achieved during the first 10 seconds). Two ROIs were selected: the dorsum of the foot and the plantar region. ICG-FI results were compared with ABI and TP. The clinical status of the foot was analysed as to whether the wound was healed, healing, similar or worse. Results - At 3-month follow-up, the clinical status was improved compared to the baseline in 39 legs (63%); the wound was completely healed or healing), but in 23 (37%), the wound status was unchanged or worse. The sensitivity and specificity of ICG-FI for the unchanged or deteriorated clinical status were 61% and 72%, respectively. In 23 cases, the clinical status had not improved and ultrasound examination revealed restenosis or occlusion in 20 (90%) patients, and a new revascularization was scheduled. In 100% of these cases, ICG-FI at follow-up showed worse results compared to the immediate postoperative ICG-FI. A reliable ABI was possible in 38 (61%) legs at the follow-up visit, and it was higher than the baseline ABI in 29 (76%) cases and unchanged/worse in 9 (24%). The sensitivity and specificity to detect a deteriorated situation were 91% and 47%, respectively. TP measurements were possible in 49 (79%) cases at the follow-up visit. For 34 (69%) cases, the TP had increased from the baseline, while 15 (31%) had worse or unchanged values. The sensitivity to detect unfavourable healing was 80%, with a specificity of 47%. In ROC, the areas under the curve (AUC) using ICG-FI, ABI and TP were 0.66 (95% CI 0.52-0.81, p=0.03), 0.69 (95% CI 0.51-0.87, p=0.05) and 0.64 (95% CI 0.47-0.80, p=0.11), respectively. ICG-FI correlated with the clinical status in 68% of the cases, as opposed to the 74% correlation achieved with ABI and 67% with TP when only cases with successful measurements were considered. However, when all patients were considered, the respective proportions for ABI and TP were only 45% and 53%, due to the fact that not all patients had ABI and TP measurements available. Conclusion - ICG-FI is useful and feasible in the surveillance of SCLI after revascularization. Unlike ABI and TP, it can be measured in all patients. ReferencesSettembre N et al. World J Surg 2017,6

Deep Circumflex Iliac Artery as an Inflow Alternative for Lower Limb Bypass: Report of a Case

Introduction: The common femoral artery (CFA) is the most favourable inflow in all types of lower limb bypass procedures. However, sometimes, the CFA cannot be used in patients with critical limb ischaemia owing to obstruction, severe calcification or previous dissection. Here, we describe how iliopopliteal bypass was successfully performed by using a reversed saphenous vein graft in a patient with total occlusion of the CFA, superficial femoral artery (SFA) and deep femoral artery (DFA) and an entirely stented external iliac artery (EIA). The deep circumflex iliac artery (DCIA), which is an artery in the pelvis that runs along the iliac crest of the pelvic bone, was used as a source of inflow. Methods: A 62-year-old man with a severely ischaemic left foot was admitted to our hospital. His third and fifth toes were necrotised with pain at rest. Computed tomography revealed complete occlusion of the left CFA, SFA and DFA with severe calcification. Additionally, the left EIA had been entirely stented at another hospital 2 years previously. Arteriography revealed that the distal site of the stent in the EIA was at the border of the CFA and that the left CFA, SFA and DFA were occluded with severe calcification. The left DCIA was the only patent artery. Results: Lower limb bypass surgery was performed. The left EIA, CFA, SFA and DFA were exposed. The left EIA was totally stented, and the CFA, SFA and DFA showed severe calcification. There was no place to clamp the EIA. Even with occlusion of the EIA with a balloon, there would have been no space to anastomose the CIA. The left DCIA was 10 mm in diameter and was well pulsating, and it evolved as a collateral artery. Considering the occlusion condition, we selected the DCIA as a source of inflow. Subsequently, the left greater saphenous vein was exposed from the saphenofemoral junction to the ankle. The popliteal artery was exposed below the knee, and confirmed to be suitable for anastomosis. After systemic heparinisation, a 3.5-mm saphenous vein graft was anastomosed to the left DCIA in an end-to-side fashion with a continuous 7-0 polypropylene suture. The distal end of the saphenous vein graft was anastomosed to the distal zone of the left popliteal artery in an end-to-side fashion with a continuous 6-0 polypropylene suture. After completion of distal anastomosis, good pulsation was observed in the dorsalis pedis artery. Postoperative three-dimensional computed tomography revealed that bypass grafts were patent and that peripheral blood flow remarkably increased (Graphic). Although the third and fifth toes remained necrotised, the rest of the left foot became warm and the pain disappeared. The patient is currently undergoing a course of physiotherapy to help him perform activities of daily living. Conclusion: The CFA has been recognised and accepted as an important inflow source in lower limb bypass procedures. However, in clinical situations where the CFA, SFA and DFA cannot be used owing to obstruction, severe calcification or previous dissection, as in the present case, the DCIA evolving as a collateral artery can be considered as an effective alternative inflow in lower limb bypass.

Limb Salvage in Diabetic Patients With Ischemic Heel Ulcers.

The purpose of this study is to investigate the outcomes of diabetic individuals with ischemic heel ulcers. The study group was composed of a consecutive sample of persons with diabetic ischemic foot ulcers managed by a preset multidisciplinary limb salvage protocol, including revascularization through endovascular technique. The outcome measures were healing, major amputation (above the ankle), and death at 1-year of follow-up. The outcomes between patients with heel ulcers (HUs) and without (NHUs) were compared. A total of 254 patients were recruited. There were 50/254 (19.7%) HUs and 204/254 (79.3%) NHUs. Overall, 190/254 (74.8%) patients healed. The rate of healing for HUs and NHUs was 30/50 (60%) and 160/204 (78.4%); P = .03, respectively. Major amputation occurred in 24/254 (9.4%) patients. The rates of major amputation for HUs and NHUs were 10/50 (20%) and 14/204 (6.9%; P = .002), respectively; 40/254 (15.7%) patients died, unhealed. The rates of mortality for HUs and NHUs were 10/50 (20%) and 30/204 (14.7%; P = .07), respectively. In HUs patients, absence of infection [95% CI = 3.1 (1.6-5.5); P = .002] and superficial ulcers [95% CI = 4.4 (2.2-9.3); P = .0001] were independent predictors of healing, whereas revascularization failure [95% CI = 8.1 (1.5.0-19.4); P = .0001], involvement of the plantar arch [95% CI = 6.3 (2.0-15.4); P = .0001], and dialysis [95% CI = 2.2 (1.3-4.5); P = .006] were independent predictors of major amputation. A multidisciplinary approach achieves good rate of limb salvage in people with diabetic ischemic heel ulcers.

Study on the mechanism of low-frequency electromagnetic field promoting the healing of ischemic foot ulcer in experimental rabbits

Objective By modeling ischemic foot ulcers in experimental rabbits, the mechanism of healing in animal models was investigated. Methods Sixty healthy male clean grade New Zealand rabbits were 3 months. The weight range was 2.1-2.5 kg. Randomly draw auording to the number, the experimental rabbits were randomly divided into 4 groups, namely, no ischemia-no ulcer-no intervention group (group A), no ischemia-no ulcer-no intervention group (group B), no ischemia-no ulcer-no intervention group (group C) and no ischemia-ulcer-intervention group (group D), with 15 rabbits in each group. Ischemic foot ulcers experimental rabbit building complete after 24 h, will naturally exposed ischemic foot ulcers in the low frequency electromagnetic field on experimental rabbit 7 d feeding experiment, the experimental rabbits ischemia crus muscle and the ulcer base were collected, and plasma by enzyme-linked immunosorbent assay (ELISA) verification tests in experimental rabbit plasma hypoxia-inducible factor 1 alpha subunit (HIF-1α), matrix metalloproteinases 9 (MMP-9) and soluble leukocyte differentiation antigen 40 ligand 1 (sCD40L1) expression level, while detecting ulcer healing area change, hematoxylin-eosin staining was used to detect and analyzed the pathological changes of ulcerated skin. Measurement data were expressed as mean±standard deviation (Mean±SD), one-way analysis of variance was used for comparison between groups, and LSD method was used for pairwise comparison. Results The concentration of MMP-9 and sCD40L1 in group D were (40.510±10.155) ng/ml and (44.580±19.138) ng/ml, respectively. Concentrations in group C were (93.210±17.838) ng/ml and (318.500±52.680) ng/ml, respectively. Group D was significantly lower than group C, and the difference was statistically significant (P< 0.000 1). The concentrations of HIF-1α in group D was (249.700±71.824) ng/ml, and that in group C was (124.830±20.110) ng/ml. The concentration in group D was significantly higher than that in group C, and the difference was statistically significant (P< 0.000 1). The concentrations of HIF-1α, MMP-9 and sCD40L1 in group B were (181.590±31.927), (78.950±16.652) and (173.670±43.048) ng/ml, respectively. The concentrations of group A were (35.420±9.916), (32.700±6.449) and (47.440±11.831) ng/ml, respectively. The concentration in group B was significantly higher than that in group A, the difference was statistically significant(P<0.000 1). The concentration of HIF-1α in group D was (249.700±71.824) ng/ml, and the concentration of group A was (35.420±9.916) ng/ml. The concentration of group D was significantly higher than that of group A, and the difference was statistically significant (P=0.000 1). The concentration of the MMP-9 in the group D was compared with the concentration of group A, and the difference was not statistically significant (P=0.207). The concentration of sCD40L1 in group D was (44.580±19.138) ng/ml, and that in group A was (47.440±11.831) ng/ml. The difference between group D and group A was not statistically significant(P=0.858). The healing area of ulcer was (1.855±0.394) cm2 in group D and (0.653±0.269) cm2 in group C. Group D was significantly higher than group C, and the difference was statistically significant (P<0.000 1). Hematoxylin-eosin staining results of ulcer skin showed that the epithelial of ischemic foot ulcer was significantly atrophied, hyperkeratinized, and the acinous cell layer was atrophied with a small amount of obvious inflammatory cell infiltration and hyperplasia of small vessels. After intervention, the symptoms were relieved. Conclusion Low frequency electromagnetic fields can promote the expression of HIF-1α in experimental rabbits, inhibit the expression of MMP-9 and sCD40L1, and promote the healing of ischemic foot ulcer. Key words: Foot ulcer; Matrix metalloproteinase 9; Electromagnetic fields; Hypoxia-inducible factor 1, alpha subunit; Rabbits

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

BackgroundWe aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan.MethodsClinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated.ResultsThe study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA.ConclusionsIn developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.

Managing Peripheral Artery Disease in Diabetic Patients: A Questionnaire Survey from Vascular Centers of the Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS)

The Mediterranean Federation for the Advancing of Vascular Surgery (MeFAVS) was founded on October 1, 2018, to enhance cooperation among vascular professionals within Mediterranean countries. Due to its prominent social and economic impact on national health systems, diabetic arteriopathy has been selected as the very first topic to be investigated by the federation. MeFAVS members were asked to reply to a questionnaire on the management of diabetic ischemic foot. Results were collected and analyzed statistically. The questionnaire consisted of 15 multiple choice answers regarding diabetic foot (DF) diagnosis and treatment. The questionnaire was submitted to 21 centers on April 20,2019. Response rate was 62%. The survey revealed that vascular surgeons, diabetologists, and wound care nurses made-up the core of the diabetic teams present in 76.9%, 69.3%, and 92.3% of the centers, respectively. Diabetic teams were most often led by vascular surgeons (53.8%) and diabetologists (42.2%), but only in 7.9% of cases by nurses. Duplex ultrasonography and computed tomographic angiography were the most commonly available tools used to assess diabetic peripheral arterial disease (PAD). Surgical wound care was undertaken by vascular surgeons in the majority of cases, and only in 46.2% of the cases to orthopedic or plastic surgeons, while nonsurgical wound care was handled by specialized nurses (76.6%) and diabetologists (53.8%). First-line revascularization was preferred over conservative treatment (61.5% vs 53.8%) and endovascular strategy (45.3%) over open (33.7%) or hybrid (21.0%) surgery. Vascular surgeons and interventional radiologists were found to be the most common performers of endovascular revascularization (92.3% and 53.8%, respectively). Amputations had an overall rate of 16.6% (range 4-30%) and a mean reintervention rate of 22.5%, and were usually performed by vascular surgeons for both minor and major interventions (84.6%) followed by orthopedic surgeons (15.4% minor and 30.8% major). The availability of a DF clinic (84.6%) and endovascular (53.8%) and open surgery (46.2%) capabilities were considered fundamental to reduce amputation rates. Especially since the introduction and spreading of new endovascular techniques for the treatment of DF, it is a common consensus amongst vascular surgeons that a standardized approach to the discipline is necessary in order to improve outcomes such as amputation-free survival and mortality and it is with this perspective and purpose that transnational cooperation amongst vascular professionals and residents in training are aiming for greater proficiency in endovascular and open surgery.

Comparison of Cryopreserved Arterial Allografts Versus Heparin-bonded Vascular Grafts in Infragenicular Bypass for Chronic Limb Threatening Ischemia

The purpose of this study was to compare cryopreserved arterial allograft (CAA) to heparin-bonded prosthesis (HBP) in infragenicular bypasses for patients with chronic limb-threatening ischemia (CLTI). This retrospective study took place in 2 university hospitals and included 41 consecutive patients treated for CLTI. In the absence of a suitable saphenous vein, an infragenicular bypass was performed using either CAA (24 cases) or HBP (17 cases). Kaplan-Meyer analysis compared primary and secondary patency and amputation-free survival rates. Binomial logistic regression analyzed risk factors for major amputation and thrombosis. The mean followup was 18.5months (±14.3) in the CAA group, 17.6 (±6.1) in the HBP group. In the CAA group, primary and secondary patency rates at 12months were 52% (±10.6) and 61% (±10.3), compared to 88% (±7.8) and 94% (±5.7) in the HBP group, respectively. The difference in patency rates was not statistically different (P=0.27 and P=0.28, respectively). The statistically significant factors of graft thrombosis were, a stage 4 from the WIfI classification (Wound Ischemia foot Infection) with a 6 times higher risk (P=0.04), and a distal anastomosis on a leg artery with a 9 times higher risk of thrombosis (P=0.03). Amputation-free survival rates at 18months were similar between the groups (CCA: 75% (±9) versus HBP: 94% (±6), P=0.11). Patients classified as WIfI stage 4 had 13 times higher odds to undergo major amputation than patients with WIfI stage 2 or 3 (95% CI, 1.16-160.93; P=0.04). The intervention was longer in the CCA group of 74min (278min±86) compared to the HBP group (203min±69). This difference was statistically significant (95% CI, 17.86-132.98), t(35)=2.671, P=0.01. CCA is not superior to HBP in infragenicular bypasses for CLTI, and may not be worth the extra cost and the longer operative duration.

P4712Hyperbaric oxygen therapy enhanced circulating levels of endothelial progenitor cells and angiogenesis biomarkers, blood flow in ischemic area in patients with peripheral arterial occlusive disease

Abstract Background Arterial atherosclerotic occlusive syndrome remains the leading cause of mortality and morbidity worldwide. Peripheral arterial occlusive disease (PAOD) is a manifestation of atherosclerosis in the lower extremities. In our previous preclinical study, hyperbaric oxygen (HBO) therapy improved ischemic PAOD mainly through an increase of vascular wall permeability and recruiting endothelial progenitor cells (EPCs) to enhance the angiogenesis and blood flow in the ischemic area. Purpose This study tested the hypothesis that hyperbaric oxygen (HBO) therapy enhanced the circulating levels of endothelial progenitor cells (EPCs), soluble angiogenesis factors and blood flow in ischemic area in patients with peripheral arterial occlusive disease (PAOD). Methods 57 consecutive patients with PAOD undergoing the HBO therapy (3 atm for 2h/each time) were prospectively enrolled into the present study. The venous blood sampling was drawn for assessing the circulating levels of EPCs and soluble angiogenesis factors prior to and during five times of HBO therapy. Additionally, skin perfusion pressure (SPP), an indicator of blood flow at ischemic area, was measured by moorVMS-PRES. Results The results demonstrated that the circulating levels of EPCs (CD34+/CD133+/CD45dim, CD31+/CD133+/CD45dim, CD34+) and soluble angiogenesis factors (VEGF/SDF-1α/HGF/FGF) were significantly increased in post-HBO therapy than in pre-HBO therapy (all p&lt;0.01). Additionally, Matrigel assay exhibited that the angiogenesis was significantly increased in post-HBO therapy than prior to the therapy (p&lt;0.001). Furthermore, the SPP was significantly increased in ischemic area (i.e., plantar foot and mean SPP of the ischemic foot) in post-HBO therapy than in pre-HBO therapy (all p&lt;0.01). Importantly, the HBO therapy did not show any complication and all the patients were uneventfully discharged without amputation. Conclusions HBO therapy augmented circulating levels of EPCs and angiogenesis factors as well as improved the blood flow in the ischemic area. Acknowledgement/Funding Kaohsiung Chang Gung Memorial Hospital, Taiwan Society of Stem Cell Research