Limb Salvage Rate Research Articles

Nonreversed great saphenous vein grafts for vascular reconstruction after resection of lower-limb sarcoma

ObjectiveReversed great saphenous vein (GSV) graft is widely used for revascularization in limb-sparing surgery for sarcoma invading great vessels. However, a mismatch in caliber between the reverse graft and the cut end of the artery can threaten graft patency. Recently, we introduced the use of a venous valvulotome to allow non-reversed GSV graft. The purpose of this study was to evaluate the safety and versatility of this technique. DesignWe retrospectively compared long-term patency and limb salvage rates between non-reversed GSV and reversed GSV in patients undergoing limb-sparing surgery for sarcoma. MethodsThirty-seven patients were included, with 21 in the non-reversed GSV group and 16 in the reversed GSV group. Patient characteristics, surgical details, and complications were reviewed from the hospital records. The patency of reconstructed vessels was assessed by contrast-enhanced CT or MRI. Statistical analyses, including Kaplan–Meier survival analysis, were employed for comparisons. ResultsThe median follow-up was 38 months. Overall graft patency was 90.4% (19 of 21 patients) in the non-reversed GSV group and 81.2% (13 of 16) in the reversed RGSV group. In the non-reversed GSV group, there was one case of graft occlusion each in the acute phase and chronic phase, but limb circulation remained intact and all limbs were spared. ConclusionNon-reversed GSV grafting with a valvulotome offers a safe and versatile alternative to reversed GSV grafts in limb-sparing sarcoma surgery. It eliminates the need for vein reversal and minimizes diameter mismatch, potentially expanding the indication for autologous revascularization in previously ineligible cases.

Contemporary outcomes after endoscopic vein harvesting for lower extremity bypass in a multicenter subspecialty practice

BackgroundEndoscopic vein harvesting (EVH) is considered the standard of care for coronary bypass procedures given the lower early morbidity from surgical wound complications. However, the use of EVH for lower extremity (LE) bypass remains controversial owing to concerns about decreased graft patency. In 2022, the BEST-CLI Trial (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) demonstrated patients undergoing surgical bypass with adequate great saphenous vein quality experienced a lower incidence of major adverse limb events and mortality than those who underwent endovascular repair. Despite these results, wound complications from large harvest site incisions remain a significant barrier preventing surgical bypass as being the preferred initial treatment. To mitigate wound complications, our practice has adopted EVH as the standard approach for harvesting bypass conduit. Here, we report our recent 5-year experience using EVH for LE bypass. MethodsOne hundred sixty-eight LE bypasses with EVH were evaluated from 2017 to 2022. The cohort included 14 vascular surgeons in 8 hospitals. The primary end point was 30-day surgical wound complications. Secondary end points included bypass patency, need for major amputation, 30-day morbidity and mortality, length of operation, and length of hospitalization. Wound complications were measured using Szilagyi's method, with class I characterized by erythema necessitating antibiotics, class II having drainage or superficial dehiscence, and class III threatening graft integrity and requiring surgical intervention. ResultsA total of 168 LE bypasses with EVH were performed on 166 patients. Of these, 65.48% were male with a median age of 68.4 ± 9.7 years. There were no wound complications related to saphenectomy. Surgical site infections occurred in 22 patients (13.10%). Seven patients (4.17%) had class I complications, 12 (7.14%) had class II complications, and 3 (1.79%) had class III complications. Primary patency at 30 days was 96.10% and 86.84% at 1 year). Seven patients (4.17%) required major amputation at 30 days. The 1-year amputation-free survival was 89.39%. The 30-day postoperative stroke, myocardial infarction, and death rates were 0.60%, 0.60%, and 2.38%, respectively. The median operative time was 3.30 ± 1.18 hours. The median length of hospitalization was 3.00 ± 3.56 days. ConclusionsEVH minimizes saphenectomy wound complications without compromising patency and limb salvage rates. Older studies suggesting lower patency rates after EVH may have been limited by older technology and inexperienced operators. Whether EVH should be the standard of care for LE bypass warrants further investigation.

Antibiotic Eluting Bone Void Filler Versus Systemic Antibiotics For Pedal Osteomyelitis

Osteomyelitis complicates 20% of patients with infected diabetic foot ulcers. In this study, two strategies for treating pedal osteomyelitis were compared in a pilot study.This was a retrospective, non-randomized, single center 2 arm cohort study, conducted between 2020-2022 involving 53 patients at a tertiary limb salvage unit. All patients were managed with debridement and proximal bone biopsy. Group A was treated with systemic antibiotics for up to 6 weeks. Group B had vancomycin or gentamycin eluting bone void filler implanted into the diseased bone medullary cavity(s) and 1 week of oral antibiotics. Patients were followed independently for the primary endpoint of osteomyelitis treatment failure and secondary endpoints of amputation free survival, wound healing, minor amputation, and treatment-limiting side-effects.Survival analysis demonstrated no significant difference in treatment failure (p=0.35) or amputation free survival (p=0.46). Limb salvage rates were 88% in Group A and 89% in Group B. Wounds healed in 85% in Group A and 89% in Group B. Minor amputations occurred in 21% in Group A and 11% in Group B. Treatment limiting side effects occurred in 6% in Group A and were absent in Group B.In conclusion, the use of antibiotic eluting bone void filler appeared safe without extended systemic antibiotics in this study. Group B had fewer intravenous lines, requirement for home nursing, and treatment limiting side effects. A larger randomized controlled trial examining longer term clinical and radiological efficacy, treatment costs and side effects is warranted. Level of Clinical EvidenceThis is a retrospective cohort study, therefore the level of clinical evidence is 2.

Association of Controlling Nutritional Status Score With Mortality in Patients With Chronic Limb-Threatening Ischemia Following Endovascular Revascularization

Chronic limb-threatening ischemia (CLTI) represents the severest manifestation of peripheral artery disease. Malnutrition is closely associated with poor clinical outcomes in patients with chronic diseases. The Controlling Nutritional Status (CONUT) score is a tool to evaluate the systemic inflammation and nutritional status. This study aimed to investigate the association of baseline CONUT score with mortality in patients with CLTI following endovascular revascularization. A single-center retrospective analysis of patients with CLTI undergoing endovascular revascularization between January 2015 and December 2022 was performed. Preoperative nutritional status was evaluated using CONUT score, which was calculated using the serum albumin concentration, total peripheral lymphocyte count, and total cholesterol concentration. A CONUT score ≥5 indicates moderate or severe malnutrition. The Kaplan-Meier and multivariate Cox proportional hazards regression were used for survival analysis and to evaluate the risk factors associated with mortality. Among 232 enrolled patients, 20.7% of patients had moderate or severe malnutrition defined by the CONUT score. During a median follow-up of 2.1 (interquartile ranges, 1.0-3.5) years, 87 (37.5%) patients died. The 3-year overall survival rate in patients with CLTI who underwent endovascular revascularization was 63.7%. The high CONUT (≥5) group had significantly worse 3-year overall survival (42.0% versus 68.8%, P=0.004) and limb salvage (73.3% versus 84.1%, P=0.005) rates than the low CONUT (<5) group. Multivariate analysis showed that high CONUT score was significantly associated with increased risk for mortality in patients with CLTI after endovascular revascularization (hazard ratio, 1.687; 95% confidence interval, 1.031-2.759; P=0.037). The present study indicated that moderate or severe malnutrition defined by the CONUT score was significantly associated with increased mortality in patients with CLTI following endovascular revascularization. Future study is required to evaluate the efficacy of nutritional intervention in these patients.

Clinical efficacy of endovascular revascularization combined with vacuum-assisted closure for the treatment of diabetic foot.

The diabetic foot is a common cause of disability and death, and comorbid foot infections usually lead to prolonged hospitalization, high healthcare costs, and a significant increase in amputation rates. And most diabetic foot trauma is complicated by lower extremity arteriopathy, which becomes an independent risk factor for major amputation in diabetic foot patients. To establish the efficacy and safety of endovascular revascularization (ER) combined with vacuum-assisted closure (VAC) for the treatment of diabetic foot. Clinical data were collected from 40 patients with diabetic foot admitted to the Second Affiliated Hospital of Soochow University from April 2018 to April 2022. Diabetic foot lesions were graded according to Wagner's classification, and blood flow to the lower extremity was evaluated using the ankle-brachial index test and computerized tomography angiography of the lower extremity arteries. Continuous subcutaneous insulin infusion pumps were used to achieve glycemic control. Lower limb revascularization was facilitated by percutaneous tran-sluminal balloon angioplasty (BA) or stenting. Wounds were cleaned by nibbling debridement. Wound granulation tissue growth was induced by VAC, and wound repair was performed by skin grafting or skin flap transplantation. Of the 35 cases treated with lower limb revascularization, 34 were successful with a revascularization success rate of 97%. Of these, 6 cases underwent stenting after BA of the superficial femoral artery, and 1 received popliteal artery stent implantation. In the 25 cases treated with infrapopliteal artery revascularization, 39 arteries were reconstructed, 7 of which were treated by drug-coated BA and the remaining 32 with plain old BA. VAC was performed in 32 wounds. Twenty-four cases of skin grafting and 2 cases of skin flap transplantation were performed. Two patients underwent major amputations, whereas 17 had minor amputations, accounting for a success limb salvage rate of 95%. ER in combination with VAC is a safe and effective treatment for diabetic foot that can significantly improve limb salvage rates. The use of VAC after ER simplifies and facilitates wound repair.

Tibial cortex transverse transport surgery improves wound healing in patients with severe type 2 DFUs by activating a systemic immune response: a cross-sectional study.

Tibial cortex transverse transport (TTT) surgery has become an ideal treatment for patients with type 2 severe diabetic foot ulcerations (DFUs) while conventional treatments are ineffective. Based on our clinical practice experience, the protective immune response from TTT surgery may play a role against infections to promote wound healing in patients with DFUs. Therefore, this research aimed to systematically study the specific clinical efficacy and the mechanism of TTT surgery. Between June 2022 and September 2023, 68 patients with type 2 severe DFUs were enrolled and therapized by TTT surgery in this cross-sectional and experimental study. Major clinical outcomes including limb salvage rate and antibiotics usage rate were investigated. Ten clinical characteristics and laboratory features of glucose metabolism and kidney function were statistically analyzed. Blood samples from 6 key time points of TTT surgery were collected for label-free proteomics and clinical immune biomarker analysis. Besides, tissue samples from 3 key time points were for spatially resolved metabolomics and transcriptomics analysis, as well as applied to validate the key TTT-regulated molecules by RT-qPCR. Notably, 64.7% of patients did not use antibiotics during the entire TTT surgery. TTT surgery can achieve a high limb salvage rate of 92.6% in patients with unilateral or bilateral DFUs. Pathway analysis of a total of 252 differentially expressed proteins (DEPs) from the proteomic revealed that the immune response induced by TTT surgery at different stages was first comprehensively verified through multi-omics combined with immune biomarker analysis. The function of upward transport was activating the systemic immune response, and wound healing occurs with downward transport. The spatial metabolic characteristics of skin tissue from patients with DFUs indicated downregulated levels of stearoylcarnitine and the glycerophospholipid metabolism pathway in skin tissue from patients with severe DFUs. Finally, the expressions of PRNP (prion protein) to activate the immune response, PLCB3 (PLCB3, phospholipase C beta 3) and VE-cadherin to play roles in neovascularization, and PPDPF (pancreatic progenitor cell differentiation and proliferation factor), LAMC2 (laminin subunit gamma 2) and SPRR2G (small proline rich protein 2G) to facilitate the developmental process mainly keratinocyte differentiation were statistically significant in skin tissues through transcriptomic and RT-qPCR analysis. Tibial cortex transverse transport (TTT) surgery demonstrates favorable outcomes for patients with severe type 2 DFUs by activating a systemic immune response, contributing to anti-infection, ulcer recurrence, and the limb salvage rate for unilateral or bilateral DFUs. The specific clinical immune responses, candidate proteins, genes, and metabolic characteristics provide directions for in-depth mechanistic research on TTT surgery. Further research and public awareness are needed to optimize TTT surgery in patients with severe type 2 DFUs.

Evaluation of arthroscopic ankle fusion for diabetic ankle fractures

Background Ankle fractures are a very common orthopedic trauma. One in eight patients undergoing ankle fixation is diabetic. Most of these patients also have additional comorbidities including peripheral arterial disease and diabetic neuropathy. Therefore, on one hand surgical intervention can pose challenges for wound healing and risk of infection, but non-operative management increases the risk for loss of reduction and therefore stresses the condition of the surrounding soft tissue. The aim of this work was to observe the radiological and functional outcome of arthroscopic ankle fusion in diabetic ankle fractures. Methods This prospective study was carried out on 20 patients, both sexes, with clinical criteria of displaced ankle fractures in diabetics, adults, closed ankle fractures, isolated trauma, diabetic patients with neuropathy and Adelaide Fracture in the Diabetic Ankle score more than or equal 5. Results Fourteen cases had solid bony union at a mean of 27.2 weeks while six cases had stable ankles with stiff fibrous nonunion at the end of the follow up period. Two of which had a breakage of distal locking screws. However, stiff fibrous nonunion of tibio-talar joint with the foot in a stable plantigrade position was considered satisfactory and no further intervention was advised. Our limb salvage rate was 100%. No below knee amputation was done. Conclusions Ankle fractures in diabetic patients are increasingly frequently encountered in comorbid patients with suboptimal overlying soft tissue integrity. Arthroscopic assisted ankle fusion can be considered a valid primary definitive treatment option to help reduce the potential perioperative soft tissue insult and associated complications. Utilizing an arthroscopic-assisted approach to this procedure is of added benefit in allowing for articular preparation and thereby reducing the risk of non-union while also minimizing additional extensive soft tissue insult in patients with underlying soft tissue compromise.

Identifying Risk Factors for Poor Outcomes Following Popliteal Vascular Injuries

IntroductionPopliteal artery injuries may have amputation rates as high as 20%. This study focuses on identifying risk factors associated with major amputations following popliteal artery injuries in a large single-center cohort. Additionally, we assess the impact of repairing or ligating concomitant popliteal vein injuries. MethodsA retrospective chart review encompassing 2011 to 2023 was conducted at a large urban level 1 trauma center. Patients with popliteal artery injuries were included. Demographics and clinical data were analyzed, and univariate and multivariate evaluations identified significant risk factors for amputation. In patients with concomitant popliteal vein injuries, we compared outcomes between those who underwent popliteal vein repair and ligation. Results188 patients with popliteal artery injuries were identified, 10 underwent index amputation and were excluded. Univariate analysis followed by multivariate analysis revealed that obesity (p= 0.0132) and neurologic deficits on arrival (p=0.0096) were associated with amputation. In the subgroup with popliteal vein injuries (N=93), there was no significant difference in amputation rates between those who had vein repair (p=0.21) and those who underwent ligation (p=0.84) on logistic regression analysis. Likewise, popliteal vein ligation did not impact duration of fasciotomy closure (p=0.20) or skin graft area (p=0.48) based on linear regression analysis. ConclusionOur study suggests that major amputations following popliteal artery injuries are more likely in obese patients with neurologic deficits. It also suggests that venous ligation in cases of concomitant popliteal vein injuries does not significantly impact early limb salvage rate. Further research is needed to determine the optimal approach for managing concomitant popliteal vein injuries.

Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis.

Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication. This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models. A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery. TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results. Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of the Omniflow II Biosynthetic Graft in Postoperative Wound Problems After Lower Limb Revascularization: A Single Center Prospective Registry

To investigate the role of the Omniflow II prosthesis in the prevention of vascular graft infection (VGI) in patients with peripheral arterial disease and to report on short-and mid-term graft-related morbidity. Patients were included in prospective registry between October 2019 and March 2023. The primary endpoint was to report infection-related problems, operation-related wound problems, and short- and mid-term graft-related morbidity. Secondary endpoint was to report the bypass patency rates and limb salvage rates. A total of 146 Omniflow II grafts were implanted in 125 patients. Sixty-seven patients (45.9%) received a femoral interposition graft, and 77 patients (52.7%) underwent ipsilateral bypass surgery (femoropopliteal or femorocrural). Forty-one patients (28.1%) underwent crural bypass surgery. Seventy-six patients (52.1%) had previous vascular operation in the groin. The mean follow-up time was 352days (range 0-1108days). 3.4% of the patients suffered a wound infection limited to the dermis, and in 8.2%, the subcutaneous tissue was involved. Five early VGI (3.4%) and one late VGI (0.7%) occurred. One year primary patency rate of above-the-knee bypass was significantly better compared to the bypass below the knee (74.5%±0.131 versus 54%±0.126 (P=0.049)). This difference was not significantly different when below-the-knee bypass surgery was compared with crural bypass surgery (54%±0.126 versus 23.8%±0.080 (P=0.098)). The performance of the Omniflow II prosthesis in the preventive setting is highly influenced by the anatomic location of the distal anastomosis. No influence on the incidence of postoperative wound problems could be observed. The rate of Omniflow II VGI in a high-risk population is similar to reported outcomes in other prosthetic grafts.

Supra-Inguinal Inflow for Distal Bypasses Have Acceptable Patency and Limb Salvage Rates

There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets. The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into 3 cohorts based on outflow targets (above-knee [AK] popliteal, below-knee [BK] popliteal, and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival (AFS), and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the AK popliteal was used in 116 (28.8%), the BK popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. BK popliteal and tibial bypasses, compared to AK popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (69.5% and 69.9% vs. 48.3%; P<0.001). Vein conduit was more often used for tibial bypass than for AK and BK popliteal bypasses (46.3% vs. 21.9% and 16.3%; P<0.001). In the perioperative period, BK popliteal and tibial bypass patients had higher reoperation rates (16.9% and 13.2% vs. 5.2%; P=0.02) and lower primary patency (89.4% and 89% vs. 95.7%; P=0.04) than AK bypass patients. At 1year, compared with AK popliteal bypasses, BK and tibial bypasses demonstrated lower primary patency (81.9% vs. 56.7% vs. 52.4%, P<0.001) and freedom from MALE (77.6% vs. 70.2% vs. 63.1%, P=0.04), although AFS was not significantly different (89.7% vs. 90.6% vs. 83.8%, P=0.19).On multivariable analysis, compared with AK popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, P=0.04). Subanalysis of patients with chronic limb-threatening ischemia demonstrated significantly higher primary patency in the AK popliteal cohort at discharge and 1 year, but no difference in AFS or freedom from MALE between the cohorts at follow-up. LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE or AFS.

The Impact of Intraoperative Vasopressor Use and Fluid Status on Flap Survival in Traumatic Lower Extremity Reconstruction.

Historically, the use of intraoperative vasopressors during free flap lower extremity (LE) reconstruction has been proposed to adversely affect flap survival due to concerns about compromising flap perfusion. This study aims to analyze the impact of intraoperative vasopressor use and fluid administration on postoperative outcomes in patients undergoing traumatic LE reconstruction. Patients who underwent LE free flap reconstruction between 2015 and 2023 at a Level I Trauma Center were retrospectively reviewed. Statistical analysis was conducted to evaluate the association between vasopressor use and intraoperative fluids with partial/complete flap necrosis, as well as the differential effect of vasopressor use on flap outcomes based on varying fluid levels. A total of 105 LE flaps were performed over 8 years. Vasopressors were administered intraoperatively to 19 (18.0%) cases. Overall flap survival and limb salvage rates were 97.1 and 93.3%, respectively. Intraoperative vasopressor use decreased the overall risk of postoperative flap necrosis (OR 0.00005, 95% CI [9.11 × 10-9-0.285], p = 0.025), while a lower net fluid balance increased the risk of this outcome (OR 0.9985, 95% CI [0.9975-0.9996], p = 0.007). Further interaction analysis revealed that vasopressor use increased the risk of flap necrosis in settings with a higher net fluid balance (OR 1.0032, 95% CI [1.0008-1.0056], p-interaction =0.010). This study demonstrated that intraoperative vasopressor use and adequate fluid status may be beneficial in improving flap outcomes in LE reconstruction. Vasopressor use with adequate fluid management can optimize hemodynamic stability when necessary during traumatic LE microvascular reconstruction without concern for increased risk of flap ischemia.

One-year limb salvage and quality of life following mechanical aspiration thrombectomy in patients with acute lower extremity ischemia

ObjectiveLower extremity acute limb ischemia (LE-ALI) is associated with high morbidity and mortality rates, and a burden on patient quality of life (QoL). There is limited medium- to long-term evidence on mechanical aspiration thrombectomy (MT) in patients with LE-ALI. The STRIDE study was designed to assess safety and efficacy of MT using the Indigo Aspiration System in patients with LE-ALI. Thirty-day primary and secondary endpoints and additional outcomes were previously published. Here, we report 365-day secondary endpoints and QoL data from STRIDE. MethodsSTRIDE was a multicenter, prospective, single-arm, observational cohort study that enrolled 119 patients across 16 sites in the United States and Europe. Patients were treated first-line with MT using the Indigo Aspiration System (Penumbra, Inc). The study completed follow-up in October 2023. Secondary endpoints at 365 days included target limb salvage and mortality. Additionally, the VascuQoL-6 questionnaire, developed for evaluating patient-centered QoL outcomes for peripheral arterial disease, was assessed at baseline and follow-up through 365 days. ResultsSeventy-three percent of patients (87/119) were available for 365-day follow-up. Mean age of these patients was 65.0 ± 13.3 years, and 44.8% were female. Baseline ischemic severity was classified as Rutherford I in 12.6%, Rutherford IIa in 51.7%, and Rutherford IIb in 35.6%. In general, baseline and disease characteristics (demographics, medical history, comorbidities, target thrombus) of these patients are similar to the enrolled cohort of 119 patients. The secondary endpoints at 365 days for target limb salvage was 88.5% (77/87) and mortality rate was 12.0% (12/100). VascuQoL-6 improved across all domains, with a median total score improvement from 12.0 (interquartile range, 9.0-15.0) at baseline to 19.0 (interquartile range, 16.0-22.0) at 365 days. ConclusionsThese 365-day results from STRIDE demonstrate that first-line MT with the Indigo Aspiration System for LE-ALI portray continued high target limb salvage rates and improved patient-reported QoL. These findings indicate Indigo as a safe and effective therapeutic option for LE-ALI.

Learning curve in tibial and pedal bypass with autologous vein graft.

The 2019 Global Vascular Guidelines recommended open bypass for patients at average risk with greater limb severity and anatomical complexity. However, the outcomes of tibial and pedal bypass (TPB) are inferior to those of above-the-knee surgical revascularization. This may be due to the technical difficulty and need for development of skills to perform TPB. However, there is a limited knowledge on the learning curve in TPB. Thus, the aim of the study is to assess this learning curve in a single-center retrospective analysis. Cases treated with TPB with an autologous vein conduit in patients with chronic limb-threatening ischemia (CLTI) at a Japanese single center from 2009 to 2022 were analyzed retrospectively. The primary endpoint was the learning curve for TPB. The study included 449 TPB procedures conducted by a single main surgeon in patients with CLTI (median age, 75 years; 309 males; diabetes mellitus, 73%; end stage renal failure with hemodialysis, 44%). The operative time decreased significantly as the number of cases accumulated (p < .001). Using the cumulative sum (CUSUM) operative time, the learning curve was estimated to be phase 1 (initial learning curve) for 134 cases (1-134); phase 2 (competent period) for 179 cases (135-313); and phase 3 (mastery and challenging period) for 136 cases (314-449). The mean follow-up period was 34 ± 31months. The 1- and 3-year limb salvage rates of 97% and 96% in phase 3 were significantly higher than those in phases 1 and 2 (p < .001, p = .029). Major adverse limb events (MALE) occurred in 117 (26%) patients, and the 1- and 3-year MALE rates of 10% and 17% in phase 3 were significantly lower than those in phases 1 and 2 (p < .001, p = .009). In the study, vascular surgeon required a learning curve of 134 TPB cases to Overcoming the learning curve for bypass was associated with improvement of medium-term outcomes for limb salvage and freedom from MALE.

Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

Optimizing the Use of Pedicled versus Random Pattern Local Flaps in the Foot and Ankle.

The aim of this study was to compare the use of pedicled local (PFs) versus random pattern flaps (RpFs) in foot and ankle reconstruction in patients with chronic, nonhealing wounds. A single-center, retrospective review of 204 patients with 118 PFs and 86 RpFs was performed. The primary outcome included rates of limb salvage. PFs were used more often in the hindfoot (44.1% versus 30.2%, P = 0.045), lateral and medial surface (39.8% versus 18.6%, P = 0.001), and wounds containing exposed bone and hardware (78.8% versus 62.8%, P = 0.018). RpFs were used more for forefoot (19.8% versus 10.2%, P = 0.053) and plantar defects (58.1% versus 30.3%, P = 0.000). RpFs had a higher rate of immediate success (100% versus 95.8%, P = 0.053), with no significant differences in rate of long-term limb salvage (77.1% versus 69.8%, P = 0.237). PFs had higher rates of ischemia requiring intervention (11.0% versus 3.5%, P = 0.048). RpFs had a higher rate of minor amputations (15.12% versus 6.8%, P = 0.053) but similar rates of major amputation (15.1% versus 16.1%, P = 0.848). There were no significant differences in rates of mortality or ambulatory status. Both RpFs and PFs remain reliable options to reconstruct defects of the foot and ankle. Optimizing the use of each flap type should consider wound characteristics. RpFs are preferred for dorsal and plantar defects, whereas PFs are protective for minor infections and preferred for deeper wounds despite a higher rate of partial necrosis.

A Free Bypass Flap for Chronic Limb-threatening Ischemia.

Recently, significant inframalleolar disease seems to increase in chronic limb-threatening ischemia (CLTI) patients, making identifying sufficient outflow vessels in the foot challenging. In these difficult situations, free tissue transfer is a valuable tool to provide a low-resistance vascular bed to the affected part. However, there remains concern that free tissue transfer may impede adequate perfusion of the higher resistance diseased vascular bed. To improve perfusion of the affected area directly, the authors have developed a concept of a free bypass flap, adding bypass surgery to free tissue transfer. After anastomosis with the recipient vessels in a conventional manner for free tissue transfer, bypass surgery to the foot is performed by anastomosis of the branch of the flap pedicle with the diseased artery to the foot. A retrospective chart review of nine CLTI patients was performed to analyze the outcomes of free bypass flap transfer between 2018 and 2023. The flap success rate was 100% (n = 9). Postoperative angiography or echo confirmed the patency of all but one bypass vessel (n = 8). There were six fatalities, however, due to causes other than foot lesions, with an average observation period of 16 months. The limb salvage rate was 89% (n = 8). A free bypass flap enhances the overall blood circulation to the foot. Due to its high patency rate of bypass vessels, it is a valuable method for preserving the limbs of highly comorbid patients with CLTI.

Open surgery of common femoral artery occlusive disease: a contemporary review.

Endovascular therapy has gradually gaining more importance for the treatment of common femoral artery (CFA) occlusive disease due to satisfactory perioperative outcomes. However, endovascular interventions seem to provide acceptable outcomes only in the short-term period. Endarterectomy still remains the gold standard with well-established mid- and long-term outcomes. The aim of this study was to analyze all appropriate studies about mid- and long-term outcomes of CFA endarterectomy, regardless of the type of technique used in the framework of a narrative contemporary review. This narrative review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The main inclusion criterion was the availability of data on isolated CFA endarterectomy including mid (1-5 years) and long (6-10 years) term results. Four studies have been selected. In the mid-term period CFA endarterectomy showed an excellent primary patency rate regardless the clinical presentation (up to 95% and 100% in intermittent claudication and chronic limb-threatening ischemia). About the type of reconstruction, a statistically significant difference was found between patchplasty and direct suture in terms of primary patency (97% vs. 89.9%, P=0.02). In the long-term period the overall primary patency rate was about 95%, regardless of the clinical condition (P=0.04). Overall long-term limb salvage rate ranged from 87% to 92%, with a relatively significant difference between intermittent claudication (100%), and chronic limb-threatening ischemia (82%) (P=0.01). Considering long-term clinical outcomes and the subsequent durability, surgical treatment is still the cornerstone for CFA occlusive disease, regardless of the type of technique used for both endarterectomy and arterial reconstruction. Due to its reduced invasiveness, high-risk patients may benefit from an endovascular-first approach.

Does Side Matter? The Impact of Free Flap Harvest Laterality on Ambulatory Function in Lower Extremity Traumatic Reconstruction.

Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction. A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann-Whitney tests were used for statistical analysis. Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8-13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0-3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733). Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component.

High Limb Salvage Rate and Improved Quality of Life Following Aspiration Thrombectomy With Indigo for Lower-Extremity Acute Limb Ischemia: Twelve-Month Results From the STRIDE Study

High Limb Salvage Rate and Improved Quality of Life Following Aspiration Thrombectomy With Indigo for Lower-Extremity Acute Limb Ischemia: Twelve-Month Results From the STRIDE Study