Lower Amputation Rates Research Articles

Effect of 3-hydrazinylquinoxaline-2-thiol hydrogel on skin wound healing process in diabetic rats

Impaired wound healing in diabetic individuals creates huge social and financial burdens for both diabetic patients and the health system. Unfortunately, the current treatment has not resulted in consistently lower amputation rates. Quinoxalines are heterocyclic compounds with multiple important pharmacological properties. Their effect on wound healing have not been closely studied. In the current work, the wound healing effect of 3-hydrazinylquinoxaline-2-thiol hydrogel is tested topically in a full-thickness excision wound in streptozotocin-induced type 1 diabetic rats. We examined the wound closure rate, expression of inflammatory factors, growth factors in addition to the histological analysis. The results revealed a significant acceleration in wound closure in the treated group compared with the control experimental animals. Histological data demonstrated enhanced re-epithelialization and collagen disposition. The healing effect was additionally evaluated by the inhibition of the inflammatory response of interleukin (IL)—1β interleukin (IL)—6, tumor necrosis factor (TNF-α) and nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) with a marked improvement of the transforming growth factor beta (TGFβ-1), antioxidant markers and collagen-1. In silico study indicated a favorable drug-like properties and toxicity profile. The present work showed that 3-hydrazinylquinoxaline-2-thiol holds great potential for the treatment of diabetic wounds.

Management of Pediatric Lower Extremity Vascular Trauma: Adult vs Pediatric Level I Trauma Centers [RETRACTED

Pediatric lower extremity vascular injury (PLEVI) is uncommon. Though epidemiologic studies exist, the availability of granular data is sparse. Additionally, few studies compare the management between adult (ATC) and pediatric (PTC) trauma centers. The objective of this study was to analyze the surgical management of PLEVIs between a Level I ATC and a Level 1 PTCs in our metropolitan area. We performed a retrospective review of all PLEVIs (age < 18 years) managed surgically between 01/2009-12/2022. Demographics, clinical and outcome data were obtained and compared between centers. Primary outcomes included amputation and fasciotomy rates. Secondary outcomes included type of vessel repair, mortality, and intensive care unit (ICU) and hospital length of stay. Seventy-nine patients were identified, 41 at the ATC and 38 at the PTC totaling 111 vessels injured. Overall, 84.8% were male. ATC patients were older (median 16.0 vs 12.5) and almost exclusively (97.6% vs 29.0%) gunshot wounds. There was no difference in ISS. The popliteal artery was the most injured vessel, ATC (50%) and PTC (40%). Vascular surgeons managed 50% of injuries at ATC vs 60.5% of injuries at the PTC (p = 0.35). Rates of arterial or venous repair, ligation, or grafting were not significantly different. Amputations were uncommon at both centers and not significantly different. Seventeen patients (44.7%) required fasciotomies at the PTC vs 21 (51.2%) at the ATC (p = 0.56). There was no significant difference in mortality, ICU, or hospital length of stay. PLEVI have acceptable outcomes (low amputation and/or fasciotomy rates, low mortality) and are managed uniformly between ATCs and PTCs. This data adds important context to the management of PLEVI. Retrospective Chart Review, Level IV.

Effects of Oxygen Therapy on Patients with a Chronic Wound: A Systematic Review and Meta-analysis.

To synthesize the effects of oxygen-based therapy on patients with a chronic wound. The authors searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for relevant randomized controlled trials from database inception. Investigators measured risk of bias using the Cochrane Collaboration's Risk of Bias tool. The included randomized controlled trials focused on the effects (short- or long-term wound healing, amputation rate, percentage of reduction in ulcer size, and poststudy transcutaneous oxygen measurement [TcPO2]) of oxygen-based therapy (including hyperbaric oxygen therapy, topical oxygen therapy, and continuous diffusion of oxygen) on patients with a chronic wound. Researchers extracted information regarding participant characteristics and primary and secondary outcomes from the included studies. Pooled effects of 31 included studies showed that patients treated with oxygen had better short-term wound healing (risk ratio [RR], 1.544; 95% CI, 1.199 to 1.987), a higher percentage reduction in the ulcer area (standardized mean difference [SMD], 0.999; 95% CI, 0.439 to 1. 599), lower amputation rates (RR, 0.529; 95% CI, 0.325 to 0.862), shorter wound healing time (SMD, -0.705; 95% CI, -0.908 to -0.501), and higher poststudy TcPO2 (SMD, 2.128; 95% CI, 0.978 to 3.278) than those in the control group. For long-term wound healing, there was no statistically significant difference (RR, 1.227; 95% CI, 0.976 to 1.542). Oxygen-based therapy improves short-term parameters of wound healing in patients with chronic wounds.

Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia.

To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.

Association between time to revascularization and limb loss in military femoropopliteal arterial injuries

ObjectiveExpeditious revascularization is key to limb salvage after arterial injuries, but the relationship between time to revascularization and amputation risk is not well-defined. We aimed to explore amputation risk based on time to revascularization in a cohort of military femoropopliteal arterial injuries. MethodsA database of vascular injuries from Iraq and Afghanistan casualties (2004-2012) was queried for femoral (common, superficial, or deep) and/or popliteal arterial injuries that underwent revascularization. Time from injury to initial revascularization (via shunt or reconstruction) was divided into groups of <3 hours, 3 to 6 hours, 6 to 9 hours, and >9 hours, and bivariate comparisons were performed. ResultsRevascularization times were available for 120 cases. Injury and treatment characteristics by time group were generally similar between time groups. Shunting and vein injuries were more common in limbs revascularized earlier, whereas blast mechanism and fasciotomy were more common with later revascularization. Ten cases (8%) underwent revascularization in less than 3 hours, 63 (53%) were revascularized in 3 to 6 hours, 33 (28%) in 6 to 9 hours, and 14 (12%) after 9 hours. Amputation rates within the cohorts were 10%, 21%, 24%, and 50%, respectively (P = .085, χ2 of amputation rates across time groups). The mean ± standard deviation revascularization time for amputated limbs was 442 ± 348 minutes vs 347 ± 183 minutes for salvaged limbs (P = .057). Amputation was performed in 19% of limbs revascularized in <6 hours and in 32% revascularized >6 hours from injury (P = .112). The >9-hour group, however, had a 50% amputation rate vs 21% for those with revascularization in <9 hours (P = .016). Fractures were more common in >9-hour limbs than <9-hour limbs (79% vs 44%; P = .016), but other limb injury characteristics were similar, with no difference in limb injury severity scores. Among 91 salvaged limbs, neither vascular nor other complications were predicted by time to revascularization. All seven >9-hour limbs had a limb complication, most commonly infection (71%), and three (42%) required a skin graft to close their fasciotomies. ConclusionsIncreasing time from injury to initial revascularization was associated with increasing rates of limb loss. Revascularization within 3 hours of injury resulted in a low amputation rate, whereas one-half of limbs treated after 9 hours were amputated. Arterial shunting was associated with earlier revascularization and should be considered a mainstay of combat casualty vascular care. Forward-deployed surgical assets play a pivotal role in providing early revascularization and reducing rates of limb loss in modern combat casualty care.

Republication of "Minimally Invasive Surgery Using the Circular External Fixator to Correct Neglected Severe Stiff Equinocavus Foot Deformities".

Stiff equinocavus deformities of the foot are challenging to treat, often requiring extensive soft tissue dissection and bone removal. These procedures frequently yield suboptimal results and not infrequently amputation. Minimally invasive surgery using a circular external fixator potentially avoids the trauma to the soft tissue and may lead to improvement in outcomes and a lower amputation rate. The objective of this study was to evaluate the efficacy of minimally invasive surgery using a circular external fixator and limited soft tissue release to correct stiff equinocavus deformities. The treatment outcome of 29 patients (31 feet) with stiff equinocavus deformities of the foot and ankle treated with minimally invasive surgery and circular external fixation were reviewed after a mean follow-up period of 63 months. Patients' demographics and cause of the deformities were recorded. Weight bearing radiographs of the foot were compared pre and postoperatively. Outcome was satisfactory (plantigrade foot with improvement/resolution of pain) in 21 of 31 extremities, fair in 6 of 31 extremities, and poor in 4 of 31 extremities. In the majority of patients, a significant improvement in the equinocavus deformities was achieved with a statistically significant improvement in calcaneus and navicular height. Two patients with Charcot-Marie-Tooth and severely insensate feet had a poor outcome, resulting in transtibial amputation. Minimally invasive surgery with gradual correction of neglected stiff equinocavus deformities using a modular circular external fixator is a reliable initial limb salvage strategy. Minimally invasive surgery and gradual correction of neglected severe stiff equinocavus deformities using the modular circular external fixator to gradually correct neglected severe stiff equinocavus deformities, is a safe initial limb salvage strategy which may simplify secondary procedures such as arthrodesis. IV.

Acute Limb Ischemia in Pediatric Intensive Care Units

To determine the outcome of children treated for acute limb ischemia (ALI) in pediatric intensive care units (ICUs). A single-center, retrospective cohort study including all patients diagnosed with ALI between 2005 and 2022 in 2 different pediatric ICUs: respiratory and cardiac ICU. Data collected included patients demographics and comorbidities, location and cause of arterial occlusion, and type and duration of therapy. Primary end point was freedom from amputation. Secondary end point was all-cause mortality. A total of 78 patients (58% male) with ALI were included in the study. Median age was 3.8months (range 0.03-201). The lower extremity was involved in 55 (70%) patients. The limb ischemia was caused by arterial instrumentation in 94% of the patients. Anticoagulation was administered as the first-line therapy in all patients. Unfractionated heparin was administered for a median duration of 5days (range 1-48). Low molecular weight heparin was continued for a median period of 28days (range 4-420). Thrombolytic therapy was administered in 5 patients and 2 required surgical revascularization, all for failure of anticoagulation therapy. Mean follow-up was 21months (range 1-188months). None of the patients required major upper or lower extremity amputations during or after the index admission. Overall survival at 30months was 68%. The causes of mortalities were unrelated to the limb ischemia. This large, single-center study demonstrates that ALI in the pediatric ICU population can be treated conservatively and is associated with a low amputation rate following nonoperative management. The favorable outcome exists regardless of the etiology of the ALI and underlying diseases.

Rational Use of Antibiotics and Education Improved Aeromonas Necrotizing Fasciitis Outcomes in Taiwan: A 19-Year Experience.

Aeromonas necrotizing fasciitis (NF) causes high rates of amputation and mortality, even after aggressive surgical debridement and antibacterial therapy. This study investigated the effects of rational use of antibiotics and education by infectious disease (ID) physicians on Aeromonas NF treatment outcomes. Retrospective review for conducted for four years (period I, without an ID physician, December 2001 to December 2005) and 15 years (period II, with an ID physician, January 2006 to March 2021). In period II, the hospital-wide computerized antimicrobial approval system (HCAAS) was also implemented. A pretest-posttest time series analysis compared the two periods. Differences in clinical outcomes, demographics, comorbidities, signs and symptoms, laboratory findings, Aeromonas antibiotic susceptibility, and antibiotic regimens were compared between the two periods. There were 19 patients in period I and 53 patients in period II. Patients had a lower rate of amputation or mortality in period II (35.8%) compared with period I (63.2%). Forty-four patients (61.1%) had polymicrobial infections. In the emergency room, the rate of misdiagnosis decreased from 47.4% in period I to 28.3% in period II, while effective empiric antibiotic usage increased from 21.1% in period I to 66.0% in period II. After the ID physician's adjustment, 69.4% received monotherapy in period II compared to 33.3% in period I. Because Aeromonas NF had a high mortality rate and was often polymicrobial, choosing an antibiotic regimen was difficult. Using the HCAAS by an experienced ID physician can improve rational antibiotic usage and clinical outcomes in Aeromonas NF.

Safety and Efficacy of All Comers Treated with a Paclitaxel Coated Balloon for Below Knee Intervention

Data on paclitaxel coated balloons (PCBs) for below knee (BTK) angioplasty exhibited conflicting efficacy results, and previous meta-analyses suggested an increased mortality and amputation risk highlighting the need for further research. The aim of this study was to investigate safety and efficacy of PCBs for BTK interventions in a real world cohort. Within a single centre cohort study, 552 consecutive patients were included undergoing BTK interventions with and without PCB use. Two year safety and efficacy results were compared in unadjusted and propensity score matched (PSM) analysis. BTK interventions were performed in 157 patients with PCB angioplasty (100% Lutonix 0.014 inch drug coated balloon; Bard Lutonix, New Hope, MN, USA) and 395 patients with plain old balloon angioplasty (POBA). The majority of interventions (> 70%) were performed for chronic limb threatening ischaemia. Mean lesion length was 20.8 ± 12.6 cm; 61.2% in the PCB and 66.7% in the POBA group were occlusions. In the PCB group, more procedures were performed for re-stenotic lesions than POBA (28.5 vs. 17.2%). In PSM analysis (128 matched pairs), the primary efficacy endpoint was freedom from clinically driven target lesion revascularisation (CD TLR), which occurred in 70.1% in the PCB and 73.1% in the POBA group at one year (p= .85; McNemar test). Survival analysis suggested lower rates of major amputations in the PCB group in unadjusted (94.4% ± 2.1 vs. 89.2% ± 1.9 in the POBA group) and PSM analyses (97.2% ± 1.6 vs. 89.3% ± 3.5) through two years, while no differences were seen for CD TLR and all cause mortality between the groups. In this all comer analysis, PCBs were found to be safe for BTK interventions with a signal towards lower amputation rates but no benefit was seen for repeat revascularisation.

Admission monocyte to high density lipoprotein cholesterol ratio predicts amputation in patients undergoing embolectomy for acute lower extremity ischemia.

Acute limb ischemia is a common clinical manifestation of embolism or thrombosis, which can lead to amputation. Increasing evidence suggests that various biomarkers can predict amputation at the time of admission. Identifying an easily obtainable and inexpensive indicator has always been a major objective. The aim of this study was to determine the predictive value of the admission monocyte count to the HDL-C ratio for a lower extremity amputation in patients undergoing embolectomy for acute limb ischemia. This retrospective, single-center study included 269 patients who underwent an emergent embolectomy. The study population was divided into two groups according to early amputation: the non-amputation group (n = 220) and the amputation group (n = 49). Two groups were compared based on various data. According to the multivariate regression analysis, patients with a higher CRP and MHR have a significantly higher amputation rate (HR: 1.148; CI: 1.075-1.225; p < 0.001 and HR: 1.547; CI: 1.003-2.387; p = 0.04, respectively). Patients with arterial back bleeding have a significantly lower amputation rate (HR: 0.106; CI: 0.02-0.558; p = 0.008). Our study demonstrated that preoperative CRP, MHR, and no arterial back bleeding after surgery were found to be independent predictors of amputation as a poor prognostic factor within 30 days after an embolectomy.

Role of Neutrophil-Lymphocyte Ratio and Mean Platelet Volume in the Outcome of Atherosclerotic Peripheral Vascular Disease Interventions

Purpose: Classically, neutrophils have been neglected in the pathophysiology of atherosclerosis. However, recent studies have highlighted their role. Similarly, the role of platelets in peripheral artery disease (PAD) has become evident now. The significance of neutrophil-lymphocyte ratio (NLR) and mean platelet volume (MPV) has been independently studied and found that elevated values are associated with poor outcomes of atherosclerotic peripheral vascular disease interventions. However, the measure of association of NLR and MPV to the outcomes of intervention has not been studied. Hence, this study was undertaken to examine the measure of association of NLR and MPV to the outcomes of atherosclerotic peripheral vascular disease interventions. Methodology: This is a prospective study conducted between January 1, 2020, and September 30, 2021, with 6 months of follow-up. Patients aged 21 years or more, diagnosed to have atherosclerotic peripheral vascular disease, and undergoing interventions (endovascular and open procedure) are included in the study. Patients &lt;21 years, not willing for any intervention, and with acute presentations were excluded. The primary endpoint assessed is graft patency at 6 months, and the secondary endpoints assessed are clinical improvement (which is a combined measure of change in ankle–brachial index, Rutherford grade, and ulcer status) at 1 and 6 months, redo procedure, and amputations within the follow-up period. Results: From January 2020 to September 2021, a total of 156 patients with atherosclerotic peripheral vascular disease fulfilled the inclusion and exclusion criteria. We observed that in 109 (69.9%) patients who had completed 6-month follow-up, 91 (83.5%) patients had graft patency and 18 (16.5%) patients had occluded graft. Independent receiver operating characteristic curve analysis of MPV and NLR showed that lower mean NLR and MPV values (cutoff taken as 10.15 for MPV) are associated with increased graft patency at 6 months than higher mean NLR and MPV values (NLR, P &lt; 0.001; MPV, P = 0.024). Discriminant analysis model developed with MPV and NLR as the set of predictors showed that NLR and MPV together are good predictors of graft patency at 6 months (Wilk's lambda: χ2 = 45.54, P &lt; 0.001). However, logistic regression analysis has shown that, in comparison to NLR, MPV is not a strong predictor of graft patency. Lower mean NLR value was associated with lower amputation rate (P &lt; 0.001), lower mortality rate (P &lt; 0.001), and higher clinical improvement rate at 1st month (P &lt; 0.001) and at 6 months (P &lt; 0.001) than patients with higher mean NLR. However, there was no statistically significant difference between two groups in predicting chance of redo procedure (P = 0.424). There was no statistically significant difference between the mean MPV values among patients who underwent amputation (P = 0.864), died (P = 0.640), or had redo procedure (P = 0.883), except for clinical improvement outcome where lower mean MPV value was associated with higher rate of clinical improvement at 1st month (P &lt; 0.001) and 6 months (P &lt; 0.001) than higher mean MPV value. Conclusion: In patients with atherosclerotic peripheral vascular disease, NLR value is a better predictor of outcomes after intervention than MPV, and lower mean NLR values are associated with increased rate of graft patency, clinical improvement, fewer amputations, and deaths.

Safety and Efficacy of Drug-Coated Balloon for Peripheral Artery Revascularization—A Systematic Review and Meta-Analysis

A review of randomized controlled trials and observational cohort studies found in the PubMed, Embase, and Cochrane databases through April 2021. In 26 studies comprising 26,845 patients who were treated by uncoated balloon (UCB) (17,770) or drug-coated balloon (DCB) (9075) angioplasty for lower extremity peripheral arterial disease (LE-PAD), DCB was associated with significantly lower vessel restenosis, reduction in major amputation, and decreased need for repeat target lesion revascularization compared with UCB. Primary patency rate was significantly higher in patients who underwent DCB angioplasty. Odds for all-cause mortality were not significantly different between the two groups. The use of DCB in LE-PAD intervention is associated with higher primary patency, lower restenosis, lower amputation rate, and decreased need for repeat revascularization with similar all-cause mortality as compared with UCB.

602 Foot burns in diabetic patients: A single center experience

IntroductionThe most significant sequelae of foot burns in diabetic patients is a non-healing wound that results in a diabetic foot ulcer, which has been a predictor for need for amputation and mortality. Even minor amputations in patients with diabetes have a significant mortality rate. Our systemic review found that when 60% of a diabetic patient cohort with foot burns was managed by skin grafting, 29% subsequently required amputations, which is concerning. The practice at our regional burn center has been to manage patients with foot burns and diabetes non-operatively with daily dressing changes, and we believe that this may result in better functional outcomes, ambulatory status, and lower amputation rates.MethodsA retrospective review of patients with diabetes and foot burns admitted to an ABA verified regional burn center was conducted. The primary outcome was amputation. Secondary outcomes were ambulatory status, wound closure, and infection. Rank sum and fisher exact tests were performed to compare patient demographics, comorbidities, uncontrolled DM (A1c >9%), and burn characteristics between patients who were treated surgically and those who received daily wound care only. These associations were subsequently evaluated with odds ratios (OR) and 95% confidence intervals (CI). A multivariable logistic regression was performed to evaluate for possible differentiating factors that resulted in maintaining ambulatory status at completion of burn care. Statistical significance was defined as p< .05.ResultsOf 75 patients identified, median TBSA burned was 2% (IQR 2), and 61% (n=46) had full thickness burns. Mean A1c at admission was 9% (SD 2). In terms of management, 9% (n=7) were treated with debridement and/or skin grafting, and 9% (n=7) later required lower extremity amputations. Infection during first admission developed in 8% (n=6). At completion of burn care, 73% had normal or same ambulatory status, and older patients were less likely to maintain ambulatory status (p=.009, OR=0.92, 95% CI=0.86-0.98). Median time to wound closure was 95 (IQR 130) days, and 12% (n=9) of wounds never fully closed. Burn depth (second vs third degree), burn location (plantar burn vs other areas), uncontrolled DM, and surgical treatment did not result in a statistically significant difference in maintaining ambulatory status at completion of burn care.ConclusionsDiabetic patients with foot burns are best managed non-operatively with daily dressing changes, and should be allowed to heal secondarily. This may result in a longer time to close the wounds, but the amputation rates were much lower when compared to surgical management. However, 5% of our cohort developed diabetic foot ulcers at completion of burn care, which is a complex disease process that carries a dire prognosis.

Individual patient data meta-analysis of patients treated with a heparin-bonded Viabahn in the femoropopliteal artery for chronic limb-threatening ischemia.

ObjectivesThe aim of the study was to analyze available data on patients treated for chronic limb‐threatening ischemia (CLTI) with the heparin‐bonded Viabahn endoprosthesis.BackgroundThe patency of self‐expanding covered stents in patients with complex femoropopliteal lesions is encouraging. However, data were mostly derived in patients with intermittent claudication. Patients with CLTI often have more advanced disease and worse outcome.MethodsAfter the abstract screening, full‐text papers were checked. Authors were approached to consider joining the consortium. Data were sent anonymously, databases were merged and an individual patient data meta‐analysis was performed. Kaplan–Meier curves were used to calculate the freedom from amputations, the amputation‐free survival, and patency rates.ResultsSeven studies were enrolled, representing 161 limbs that were treated for CLTI. Median lesion length was 28.0 cm (interquartile range 25.0–33.0 cm) and 82.7% were chronic total occlusions. The technical success rate was 98.1% and the 30‐day mortality 1.9%. Through 2‐year follow‐up, the freedom‐from‐major‐amputations was 99.3%, with an amputation‐free survival of 78.8%. The freedom‐from‐loss‐of primary, primary‐assisted, and secondary patency was 70.4%, 71.8%, and 88.2%, respectively, at 1‐year and 59.5%, 62.7%, and 86.1% at 2‐year follow‐up, respectively. The reintervention‐free survival was 62.2% at a 2‐year follow‐up.ConclusionsTreatment of femoropopliteal disease in CLTI patients with the use of the heparin‐bonded Viabahn is safe and effective with favorable clinical outcomes and low amputation rates. Reinterventions are needed in a subset of the population to maintain endoprosthesis patency. Close follow‐up using duplex is recommended to detect potential edge stenosis, allowing treatment before device occlusion.

Resource use within a multidisciplinary foot team clinic

The establishment of multidisciplinary foot team clinics reduces the risk of amputation, but little is known about its resource requirement. This study evaluates the service's resource use for first visit attendees to an established multidisciplinary foot team clinic. A retrospective evaluation was performed for new referrals to the clinic over six months, including demographics, resource use and clinical outcome. Data were extracted electronically with retrospective review of electronic clinical notes. A total of 240 first visit attendees were analysed. Mean age was 64±15years, 63% were male, 72% had type 2 diabetes, 16% had type 1 diabetes, 15% had a previous amputation, and 40% had a previous ulceration. Common presentations were ulcers (62%), osteomyelitis (11%), Charcot foot (19%), foot ischaemia (17%), post-surgical wounds (13%), and osteomyelitis (11%). At first attendance, 79% of patients required specialist services including diabetologist (45%), joint vascular review (23%), joint orthopaedics services (8%), dermatologist (2%), and orthotics services (1%). A total of 4% of patients had complex debridement, 0.4% total nail excision, 0.8% pus drainage, 3% cast-related procedures, and 1% vacuum-assisted dressing. Of the patients, 4% were admitted to hospital, 38% had vascular duplex investigations, 7% had a deep vein thrombosis scan, 16% had magnetic resonance imagine (MRI), and 5% had a bone scan. A functional multidisciplinary foot team clinic requires significant resources-both clinical and administrative-for prompt investigations and revascularisation to sustain low amputation rates. Regular appraisal of resource use helps with clinic and pathway planning.

Safety and efficacy of drug-coated balloon for peripheral artery revascularization-A systematic review and meta-analysis.

The relative merits of the drug-coated balloon (DCB) versus uncoated balloon (UCB) angioplasty in endovascular intervention for patients with symptomatic lower extremity peripheral arterial disease (PAD) remains controversial. Online databases were queried with various combinations of keywords to identify relevant articles. Net adverse events (NAEs) and its components were compared using a random effect model to calculate unadjusted odds ratios (ORs). A total of 26 studies comprising 26,845 patients (UCB: 17,770 and DCB: 9075) were included. On pooled analysis, DCB was associated with significantly lower odds of NAE (OR: 0.47, 95% confidence interval [CI]: 0.36-0.61), vessel restenosis (OR: 0.46, 95% CI: 0.37-0.57), major amputation (OR: 0.68, 95% CI: 0.47-99), need for repeat target lesion (OR: 0.38, 95% CI: 0.31-0.47) and target vessel revascularization(OR: 0.62, 95% CI: 0.47-0.81) compared with UCB. Similarly, the primary patency rate was significantly higher in patients undergoing DCB angioplasty (OR: 1.44, 95% CI: 1.19-1.75), while the odds for all-cause mortality (OR: 0.96, 95% CI: 0.85-1.09) were not significantly different between the two groups. A subgroup analysis based on follow-up duration (6 months vs. 1vs. 2 years) followed the findings of the pooled analysis with few exceptions. The use of DCB in lower extremity PAD intervention is associated with higher primary patency, lower restenosis, lower amputation rate, and decreased need for repeat revascularization with similar all-cause mortality as compared to UCB.

Single stage versus two-stage orthoplastic management of bone infection

IntroductionBone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. MethodsUsing an existing 2009–2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. ResultsA total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. ConclusionsThe single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.

Journal of Vascular Surgery – January 2022 Audiovisual Summary

Hi! I am Peter Gloviczki from Mayo Clinic, Editor-In-Chief of the Journal of Vascular Surgery (JVS). We hope you found peace and happiness during the Holidays and you and your family are healthy and safe. I am happy to introduce four excellent papers we published in the 2022 January issue of the JVS. They are freely available to read or full-text download for the next 2 months. Our first article is the Editors’ Choice and our CME article this month, entitled “The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction,” by Dr Kakra Hughes and colleagues from Maryland and Washington, D.C.1Hughes K. Olufajo O.A. Wright K. Roby D.H. Fryer C.S. Wright J.L. et al.The influence of socioeconomic status on outcomes of lower extremity arterial reconstruction.J Vasc Surg. 2022; 75: 172-180Google Scholar In this multicenter retrospective study, outcomes of lower extremity revascularizations for peripheral artery disease in over 131,000 patients were determined using the Nationwide Readmissions Database. Compared to patients in the lowest quartile of median household income (MHI), those in the highest quartile had lower rates of amputation and less readmissions. However, subsequent revascularization and mortality rates were similar across the groups. The authors concluded that a lower socioeconomic status was associated with worse outcomes and that improving results of lower extremity arterial reconstructions may involve addressing socioeconomic disparities. The next article I would like to introduce is titled “A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections,” written by Dr Tomaz Mesar and colleagues from Norfolk, Virginia.2Mesar T. Alie-Cusson F.S. Rathore A. Dexter D.J. Stokes G.K. Panneton J.M. A more proximal landing zone is preferred for thoracic endovascular repair of acute type B aortic dissections.J Vasc Surg. 2022; 75: 40-48Google Scholar In this single-center retrospective study, 83 patients underwent thoracic endovascular aortic repair (TEVAR) for complicated acute type B aortic dissection. The proximal landing zone was zone 2 in 48 and zone 3 in 35 patients. At 36 months those with zone 3 TEVAR needed significantly more aortic reinterventions and this group also had significantly lower freedom from aortic related events. These data suggest that these patients may benefit from a more aggressive proximal landing zone even if left subclavian revascularization has to be performed. The third article you should all read is entitled “Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.”3Li J. Xia L. Ma M. Feng X. Wei X. Outcomes of intramural hematoma involving the ascending aorta and extending into the descending thoracic aorta.J Vasc Surg. 2022; 75: 58-66Google Scholar This paper was written by Dr Jiangtao Li and colleagues from Wuhan, China. Out of 135 patients with acute intramural hematoma of the ascending aorta that extended into the descending thoracic aorta, 104 patients underwent TEVAR of the descending thoracic aorta and 31 were treated with medical therapy (MT) alone. Those who had TEVAR had higher freedom from adverse aorta related events and they also had a significantly better survival rate than those who had medical therapy. In the MT group, patients with renal insufficiency had most adverse aorta related events. The final article this month is on “The natural history of large abdominal aortic aneurysms in patients without timely repair,” written by Dr Elizabeth Lancaster and co-authors from San Francisco, Oakland, Pasadena, and South San Francisco, California.4Lancaster E.M. Gologorsky R. Hull M.M. Okuhn S. Solomon M.D. Avins A.L. et al.The natural history of large abdominal aortic aneurysms in patients without timely repair.J Vasc Surg. 2022; 75: 113-121Google Scholar Of 3248 patients with large aneurysms, 2215 (68%) patients underwent repair and 1033 (32%) did not undergo repair. The 3-year cumulative incidence of rupture was 3.4% for initial AAA size 5.0 to 5.4 cm (women only), 2.2% for 5.5 to 6.0 cm, 6.0% for 6.1 to 7.0 cm, and 18.4% for >7.0 cm. Women with AAA size 6.1 to 7.0 cm had a 12.8% incidence of rupture, while it was only 4.5% for men. In this large cohort, annual rupture rates for large AAAs were lower than previously reported, with possible increased risk in women. These were just four of the many excellent papers we published in the January issue of the JVS. Please read our journals, follow us on social media and send us great manuscripts for publication. We wish you and your family a Happy New Year! Thank you for watching and see you next time for the highlights of the February issue of the Journal of Vascular Surgery. The video accompanying this article may be found online at www.jvascsurg.org. https://www.jvascsurg.org/cms/asset/3f089146-0e7e-4ffd-87a7-6ddf476c6fa6/mmc1.mp4Loading ... Download .mp4 (264.52 MB) Help with .mp4 files Video

Geographic and Socioeconomic Disparities in Major Lower Extremity Amputation Rates in Metropolitan Areas.

BackgroundRates of major lower extremity amputation in patients with peripheral artery disease are higher in rural communities with markers of low socioeconomic status, but most Americans live in metropolitan areas. Whether amputation rates vary within US metropolitan areas is unclear, as are characteristics of high amputation rate urban communities.Methods and ResultsWe estimated rates of major lower extremity amputation per 100 000 Medicare beneficiaries between 2010 and 2018 at the ZIP code level among ZIP codes with ≥100 beneficiaries. We described demographic characteristics of high and low amputation ZIP codes, and the association between major amputation rate and 3 ZIP code–level markers of socioeconomic status—the proportion of patients with dual eligibility for Medicaid, median household income, and Distressed Communities Index score—for metropolitan, micropolitan, and rural ZIP code cohorts. Between 2010 and 2018, 188 995 Medicare fee‐for‐service patients living in 31 391 ZIP codes with ≥100 beneficiaries had a major lower extremity amputation. The median (interquartile range) ZIP code–level number of amputations per 100 000 beneficiaries was 262 (75–469). Though nonmetropolitan ZIP codes had higher rates of major amputation than metropolitan areas, 78.2% of patients undergoing major amputation lived in metropolitan areas. Compared with ZIP codes with lower amputation rates, top quartile amputation rate ZIP codes had a greater proportion of Black residents (4.4% versus 17.5%, P<0.001). In metropolitan areas, after adjusting for clinical comorbidities and demographics, every $10 000 lower median household income was associated with a 4.4% (95% CI, 3.9–4.8) higher amputation rate, and a 10‐point higher Distressed Communities Index score was associated with a 3.8% (95% CI, 3.4%–4.2%) higher amputation rate; there was no association between the proportion of patients eligible for Medicaid and amputation rate. These findings were comparable to the associations identified across all ZIP codes.ConclusionsIn metropolitan areas, where most individuals undergoing lower extremity amputation live, markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation. Development of community‐based tools for peripheral artery disease diagnosis and management targeted to communities with high amputation rates in urban areas may help reduce inequities in peripheral artery disease outcomes.