Amputation Research Articles

Training in the Use of Myoelectric Prostheses Through the Combined Application of Immersive Virtual Reality, Cross-education, and Mirror Therapy

ABSTRACT Introduction During the rehabilitation process (RHB) of the patient with traumatic upper-limb amputation, the use of immersive virtual reality (IVR) facilitates the incorporation of the prosthesis into the body schema. This reinforces and enhances sensorimotor and cognitive stimulation to improve motor learning and motor patterns, while normalizing global gestures. Objectives The aims of this study were to implement retraining of gestural acquisition and prosthetic control in patients with upper-limb injuries and amputations through IVR, and to then incorporate this in the normalization of functional patterns in activities of daily living (ADLs) with the work of “cross-education” as well as the therapy of observation of actions—mirror therapy to enhance the joint effect of the approach with IVR. Methods Standard sessions were established for transradial and transhumeral trauma patients with upper-limb amputation and traumatic injuries within the rehabilitation treatment. During the sessions, games and virtual environment were used. The software ran in desktop mode using a “Leap Motion” or for immersive versions of 3D glasses (Oculus Rift S). Results The application of IVR in combination with conventional treatment obtained significant benefits for functionality. These included learning correct motor execution as well as motivational and emotional state with distal traumatic injuries and upper-limb amputations with or without myoelectric prosthesis, obtaining 5.6 on average on the GROC (global rating of change) scale. Conclusions Immersive virtual reality shows benefit for the normalization of motor learning of functional patterns in DLA and on the emotional, motivational level of the patient. Clinical Relevance The integrated combination of cross-education, mirror therapy, and immersive virtual reality may represent greater acquisition of motor patterns in the prosthetic training of patients with upper-limb amputation.

The MangLE score: A novel simple tool to identify patients who are unlikely to require amputation following severe lower extremity injury

BACKGROUND There are no validated and sensitive models that can guide the decision regarding amputation in patients with mangled lower extremities. We sought to describe a simple scoring model, the Mangled Lower Extremity (MangLE) score, which can predict those who are highly unlikely to need an amputation as a means to direct resources to this cohort. METHODS This is a retrospective study using the 2013–2021 American College of Surgeons Trauma Quality Improvement Program data set. Adult patients with a mangled lower extremity, defined as a crush injury or a fracture of the femur or tibia combined with severe soft tissue injury, arterial injury, or nerve injury, were included. Patients who suffered a traumatic lower extremity amputation, underwent amputation within 24 hours of admission, or who died within 24 hours of admission were excluded. Patients were divided into those who did/did not undergo amputation during their hospital stay. Demographics, injury mechanism, Injury Severity Score, and Abbreviated Injury Scale score, initial vital signs, and comorbid conditions were abstracted. A logistic regression model was constructed and the top five most important variables were used to create the score. RESULTS The study includes 107,620 patients, of whom 2,711 (2.5%) underwent amputation. The five variables with the highest predictive value for amputation were arterial injury, lower-extremity Abbreviated Injury Scale score of ≥3, crush injury, blunt mechanism, and shock index. The lowest possible MangLE score was 0, and the highest was 15. The model demonstrated an excellent predictive ability for lower extremity amputation in both the development and validation data set with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval, 0.80–0.82) and 0.82 (95% confidence interval, 0.81–0.84), respectively. The negative predictive value for a score of <8 is 99%. CONCLUSION The MangLE score is able to identify patients who are unlikely to require amputation. Resources for limb salvage can be directed to this cohort. LEVEL OF EVIDENCE Prospective and Epidemiologic; Level IV.

Psychosocial and personal predisposing factors of frostbite injury and associated amputation: a systematic review

Abstract Objective To date, systematic reviews of frostbite injuries predominantly focus on the treatment of frostbite, which narrows the scope of prevention and disregards the impact of frostbite-related predisposing factors. Comprehensively synthesizing relevant evidence to understand the psychosocial and personal predisposing factors to frostbite injury and related amputation would provide new insight into frostbite injury prevention. This review investigated the psychosocial and personal predisposing factors of frostbite injury and associated amputation. Methods Databases, including Embase, PubMed, and PsycINFO, were systematically searched for relevant studies. Two independent reviewers performed the screening, data extraction, and quality assessment. Inclusion criteria were studies that reported cold injury, predisposing factors for frostbite injury or related amputations, and assessed the relationship between a predisposing factor and the frostbite injury or amputation outcome based on a descriptive or inferential test. Results Thirty-six (36) studies met the inclusion criteria; 29 reported on both frostbite injury and amputations, and seven reported on only frostbite injury. Six psychosocial predisposing factors were observed in 28 out of the 36 studies reviewed, which included people experiencing homelessness, low socioeconomic status, alcohol intoxication/abuse, smoking, psychiatric disorders, and substance use. Personal predisposing factors identified included inadequate/improper winter clothing, delay in seeking medical care, and lack of knowledge of how to deal with the cold. Conclusions While it is crucial to allocate additional resources and research toward improving the treatment of individuals affected by frostbite injuries and associated limb loss, it is equally important to direct efforts toward addressing the psychosocial and personal predisposing factors that predispose individuals to these injuries and amputations.

Incidence and Risk Factors for Amputations in Persons with Diabetes Mellitus: A Retrospective Cohort Study.

The aim of this study was to identify and analyze the incidence rate of amputations and their risk factors in people with Diabetes Mellitus (DM) in two specialized outpatient clinics in Brazil. This is an epidemiological, retrospective cohort study using data collected from electronic health records of 281 adult diabetic patient types 1 or 2; attended in specialized outpatient service between 2015 and 2020. Statistical analyses were performed using the 2 sample t-test or Wilcoxon-Mann-Whitney test, for quantitative variables, and the Pearson's χ2 test or Fisher's exact test for categorical variables. The investigation of the risk factors for amputation was carried out through logistic regression. The study was approved by ethical committee. The sample mean age was 65.6 years (SD 13.05), predominating male gender n = 211 (75%), type 2 DM n = 223 (86.7%), with cardiovascular disease n = 143 (63.2%), and about 68.7% (n = 156) with peripheral arterial disease (PAD). Seventy-seven had lower limb amputation (LLA), with a rate incidence of 31.9% during five years. Logistic regression analysis showed the following associations with amputation: Diabetic peripheral neuropathy increased the rate of amputation by 3.6 times (OR = 3.631, 95% CI = 1.214-11.353; P = .022), and peripheral arterial disease increased by 10 times (OR = 10.631; 95% CI = 2.969-57.029; P = .001). The LLA in individuals with DM in two specialized outpatient services was higher compared to international literature; DPN and PAD were confirmed as risk factors for amputation, according to literature. This finding suggests that the study population faces an increased risk of amputation, highlighting the urgent need for targeted interventions and implementing robust preventive strategies to transform the current scenario and mitigate these severe outcomes. A comprehensive approach is essential to proactively address the underlying issues and reduce the prevalence and impact of amputations in Brazil.

An environmental scan of limb loss rehabilitation centers across Canada.

The clinical landscape of limb loss rehabilitation across Canada is poorly delineated, lacks standard rehabilitation guidelines, and is without a shared clinical database. To address these gaps, the objective of the present study was to undertake an environmental scan of the rehabilitation centers across Canada that provide inpatient and/or outpatient services to the limb loss community. An environmental scan was conducted to describe the rehabilitation service structure, program services, and outcome measures of sites across Canada. A survey was sent to 36 rehabilitation centers providing care to people with amputations. Of the 36 centers, 31 completed the survey (11 = Ontario; 8 = Quebec; 6 = British Columbia; 2 = Saskatchewan; 2 = New Brunswick; 1 = Alberta; 1 = Manitoba). Twenty-five provided both inpatient and outpatient services, 1 provided inpatient care only, and 5 provided only outpatient services. Interprofessional services were provided to a wide range of upper extremity amputation and lower extremity amputation patient populations. Range of motion was the most commonly collected outcome for both patients with upper extremity amputation and lower extremity amputation. With regard to prosthetics and orthotics fabrication, 9 of the sites had these services on-site while 15 had off-site fabricators, 6 had both, and 1 provided no response. Our findings highlight that limb loss rehabilitation and prosthetic care delivery is variable across Canada with respect to clinical team members, locations of services, and complementary services such as mental health treatments and peer support groups.

Study protocol: randomized phase III trial of neo-adjuvant and adjuvant chemotherapy vs. immediate surgery and adjuvant chemotherapy for localized soft tissue sarcoma: Japan Clinical Oncology Group study JCOG2102 (NACLESS).

The optimal timing of surgery and the number of courses of perioperative chemotherapy for high-risk soft tissue sarcoma patients are still controversial. Tumour growth during neoadjuvant chemotherapy led to limb amputation in some patients. This study aims to confirm the non-inferiority of surgery and three courses of adjuvant chemotherapy with adriamycin (30mg/m2, days 1 and 2) plus ifosfamide (2g/m2, days 1-5) compared with our standard treatment of three courses of neoadjuvant chemotherapy and surgery followed by two courses of adjuvant chemotherapy with adriamycin plus ifosfamide for localized high-risk soft tissue sarcoma patients. This is a multi-center, two-arm, open-label, randomized phase III trial. The primary aim is to confirm the non-inferiority in overall survival (margin: hazard ratio of 1.61). This is the first randomized controlled trial to compare neoadjuvant chemotherapy and immediate surgery for soft tissue sarcoma. This trial was initiated on 16 November 2022 and registered with the Japan Clinical Trials Registry (jRCTs031220446).

Management of Diabetic Foot Ulcer - A Case Report

Due to sedentary lifestyle of today, diabetes mellitus is becoming a common illness. One of the complications of diabetes mellitus, the primary cause of lower limb amputations, is diabetic foot ulcers. It affects 15% of all diabetes mellitus patients and occurs before lower limb amputation in 84% of people with diabetic foot ulcers. Controlling blood sugar levels, debridement, improved dressings, and offloading techniques are all necessary for the treatment of diabetic foot ulcers. Acharya Sushruta has listed sixty different forms of treatment in the Ayurvedic literature. He has placed particular emphasis on Vranashodhana and Ropana. Blood sugar management with Arogyavardhini Vati, wound debridement and appropriate wound care are all part of the treatment of diabetic foot ulcers. It took a month for the ulcer to fully heal, and throughout that time, the patient's ability to carry out daily tasks improved. The Ayurvedic treatment that was implemented has shown encouraging outcomes in the management of diabetic foot ulcer. It is imperative to conduct more randomised controlled trials in this area of study.

Osseointegration: A new approach to improve functional performance of prostheses – a systematic review of the literature

Background: Individuals with amputations experience functional limitations in their daily activities, depending on the level of their injuries. They often encounter problems with socket-based prostheses. Osseointegration is a new method in prosthetic rehabilitation that aims to enhance the performance of amputees and reduce the issues associated with current prostheses. The objective of this review was to assess the advantages and disadvantages of this novel approach in the rehabilitation of amputees. Method: A search was conducted in various databases, including Google Scholar, PubMed, ISI Web of Knowledge, Embase, and Scopus. The search terms used were “osseointegration,” “prosthesis,” and “amputation.” The quality of the studies was evaluated using the Down and Black tool. Results: The search using the aforementioned keywords yielded 18 papers. Out of these, 10 papers focused on the use of osseointegration for lower limb amputations, while 5 papers focused on upper limb amputations. Additionally, 3 papers examined the occurrence of stump infections associated with this method. The quality of the studies ranged from 15 to 20. Conclusion: Based on the available literature, osseointegration addresses some of the challenges associated with socket-based prostheses. Furthermore, it improves the performance of prostheses. However, there are several issues with this method, including high costs, stump infections, and the need for extensive expertise to insert the implant. Further large-scale studies are necessary to determine the various limitations and advantages of this approach for different levels of amputations.

The Potential Impact of SGLT2-I in Diabetic Foot Prevention: Promising Pathophysiologic Implications, State of the Art, and Future Perspectives—A Narrative Review

The impact of diabetic foot (DF) on the healthcare system represents a major public health problem, leading to a considerable clinical and economic burden. The factors contributing to DF’s development and progression are strongly interconnected, including metabolic causes, neuropathy, arteriopathy, and inflammatory changes. Sodium–glucose cotransporter 2 inhibitors (SGLT2-i), novel oral hypoglycemic drugs used as an adjunct to standard treatment, have recently changed the pharmacological management of diabetes. Nevertheless, data about the risk of limb amputation, discordant and limited to canagliflozin, which is currently avoided in the case of peripheral artery disease, have potentially discouraged the design of specific studies targeting DF. There is good evidence for the single immunomodulatory, neuroprotective, and beneficial vascular effects of SGLT2-i. Still, there is no clinical evidence about the early use of SGLT2-i in diabetic foot due to the lack of longitudinal and prospective studies proving the effect of these drugs without confounders. This narrative review aims to discuss the main evidence about the impact of SGLT2-i on the three complications of diabetes implicated in the development of DF, the state of the art, and the potential future implications.

Differences in Walking Speed of SACH Foot And Single Axis Foot in Transtibial Prosthesis User

Background: Lower limb amputation causes disruption of limb function, one of which is the ability to walk. One of the walking aids that can be used is a transtibial prosthesis. A transtibial prosthesis consists of a socket, shank and foot components. The choice of foot type and the use of a transtibial prosthesis is one of the factors that influence walking speed. SACH foot and single axis foot are the types of foot that are often used by prosthesis users Aims: To determine the difference in walking speed of SACH Foot and Single Axis Foot in transtibial prosthesis users. Method and Subjects: Using quantitative research, observational method with cross sectional design. The subjects of this research were users of transtibial prosthesis type SACH foot and single axis foot. The sample for this study consisted of 28 people. The measuring instruments used in this research are 10 MWT (Meter Walk Test). Results: Based on statistical tests, the results showed that there were differences in walking speed between SACH foot and single axis foot type transtibial prosthesis users. Where the p value <0.05 is 0.000 with an effect size of 0.81, which means it has a high or strong difference effect. Conclusion: There is a difference in walking speed, namely the walking speed of users of single axis foot transtibial prosthesis is faster than SACH foot. So, it is recommended to prefer using a single axis foot in users of transtibial prosthesis, especially at moderate activity levels. The limitations of this research are that there are not many subjects and the foot types are less diverse. Future research can be developed with other types of foot prosthesis and measurement of gait parameters

A framework for perioperative care for lower extremity major limb amputation: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

A framework for perioperative care for lower extremity major limb amputation: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

Listening to children with lower limb loss: Rationale, design, and protocol for delivery of a novel globally applicable research toolkit-Prosthetic user needs, quality of life, pain, and physical function.

Rehabilitation after childhood lower limb loss is complex and dependent on multiple stakeholders and environmental factors. While research with adults underscores the importance of involving prosthetic limb users and caregivers in discussions to drive innovation, children are often excluded or not effectively engaged. This protocol lays out the development and implementation protocol for an internationally applicable research toolkit which has been designed and evaluated around the essential presence of the child. Research domains span their unique prosthetic needs, quality of life, pain, and mobility. Cohorts of children in contrasting environments were identified (Cambodia, Gaza Strip, and the UK) to provide a comprehensive global understanding of the child with lower limb loss. A literature review revealed a lack of appropriate tools for identifying paediatric prosthetic user requirements leading to the development of novel interview guides for each key stakeholder: child, caregiver, and prosthetist. The child's guide centred around enjoyment and engagement using card games and activities. A panel of experts in paediatric limb loss and mental health rigorously reviewed the guides. Guides were integrated with existing validated measures for quality of life, pain, and mobility to form a comprehensive toolkit. The toolkit was successfully piloted with 5 children, their families, and 2 prosthetists. This protocol lays out the toolkit rationale and implementation plan (Jan 2023 to Dec 2025). This work offers the opportunity for this cohort to enjoyably engage with research that seeks to radically improve prospects for all children living with limb loss. The outlined best practices ensure ethical considerations when working with vulnerable cohorts. This study is approved to cover implementation at all geographical locations as well as the researcher institutions. Results will be disseminated through national and international conferences, as well as through manuscripts in leading peer-reviewed journals.

Improving peripheral artery disease screening and treatment: a screening, diagnosis, and treatment tool for use across multiple care settings.

Peripheral artery disease (PAD) is an atherosclerotic disease that contributes to significant morbidity and mortality, including loss of limb, myocardial infarction (MI), stroke, and death. Treatment options are often underutilized. A major limiting factor in PAD care is the ability to efficiently identify and screen at-risk patients. A PAD patient screening and clinician decision support tool was created to improve access to high-quality, evidence-based care to drive improved clinical outcomes. The tool identifies known PAD risk factors and presenting symptoms, in combination with objective data obtained via the ankle-brachial index (ABI). The tool utilizes this data to drive PAD diagnosis, risk assessment, and treatment, and it is adaptable across multiple care settings, by varied health professions. The implementation of a PAD screening and treatment toolkit enhances anticoagulation and PAD stewardship, and it has been integrated into use across various care settings.

How timing and preexisting pain affect outcomes of TMR: a systematic review

Introduction: Targeted muscle reinnervation (TMR) is increasingly common in the care of major limb amputation to limit amputation-related pain. This review aims to elucidate how chronic pain states and length of delay prior to TMR affect its success and outcomes. Methods: Manuscripts were collected from three databases. Articles were first screened and excluded based on exclusion criteria. The remaining manuscripts were independently reviewed to determine inclusion. Article and patient demographics, as well as pain outcomes, were extracted. Data were analyzed based on pain condition, amputation vs. neuroma, and time from amputation/injury to surgery. Results: The literature search yielded 723 articles, with 41 meeting the inclusion criteria. Twenty-one articles included patients with residual limb pain (RLP) and phantom limb pain (PLP), including 14 on amputation and 6 on neuroma excision. Five articles included cancer-related amputation. Complex Regional Pain Syndrome (CRPS) was discussed in 3 articles, ischemia or infection in 2 articles, and neurofibromatosis 1 in 1 article. Twenty-two articles described TMR at the time of amputation. Conclusions: TMR is effective at preventing neuroma formation and limiting pain when performed at the time of amputation. Delayed patients had a greater improvement in RLP but less of an improvement in PLP, when assessed against immediate TMR patients who were compared to non-TMR standard amputees. In the presence of chronic pain states, such as CRPS, there is also improved analgesia. However, current clinical data are limited, indicating a need for further research into the use of TMR for chronic pain management.

Match internal load in wheelchair basketball games – an exploratory study

ABSTRACT This study aimed to compare the match internal load according to the type of disability at different moments in the wheelchair basketball game and the effect of playing the last 5 min of the half on Lactate (LA+) concentrations. Thirty athletes (34.4 ± 6.8 years) from 5 wheelchair basketball Brazilian teams were analysed during five official games. For the analyses, athletes were separated by disability [spinal cord injury, polio sequels and lower limb amputation]. A generalised estimating equation analysis was performed to verify the effects of moment, disability and playing the last 5 min of each period on the La+ concentrations. No significant differences were found between disability groups for the TRIMP and the La+ concentrations at different moments in the game. The results pointed out that unbalanced games seem to cause higher lactate concentrations in the first period of the game, especially in players who end up playing in the second quarter. Finally, unbalanced games, whether the player finishes playing the game, seems not to influence the final lactate concentrations. The internal load of the WB game does not differ in the different disabilities, and, in unbalanced games, the players finish the game with low concentrations of lactate.

Doppler findings before and after endovascular treatment in peripheral artery disease

Aims: Peripheral arterial disease is a significant health problem affecting approximately 50 million people in the United States and Europe, which can lead to disability, limb loss, and poor quality of life. The incidence of cardiovascular disease is 2–3 times higher in patients with peripheral arterial disease. This is the main cause of significant morbidity and mortality. In this study, we aimed to share our early Doppler findings and technical success in patients who underwent endovascular procedures in our clinic. Methods: The radiological findings of patients who applied to our clinic for treatment in the last 6 months were evaluated retrospectively and the results were analyzed with descriptive statistical methods. Results: Patients with peripheral arterial occlusion or sever stenosis treated with endovascular treatment showed significant increase in lower extremity arterial flow evaluated by color Doppler ultrasound regardless of endovascular technique. Conclusion: Endovascular interventional methods for the treatment of lower extremity peripheral arterial disease are a method that provides an increase in lower extremity arterial flow demonstrated by Doppler ultrasonography.

Targeted Muscle Reinnervation Compared to Standard Peripheral Nerve Management Following Amputation: A Systematic Review and Meta-Analysis.

Chronic pain remains a significant challenge for individuals following limb amputation, with incidence of painful neuromas, phantom limb pain (PLP), and residual limb pain (RLP). Targeted muscle reinnervation (TMR) is a surgical technique designed to restore motor control information lost during amputation by redirecting residual nerves to new muscle targets. This systematic review and meta-analysis aims to compare patient-reported and functional outcomes following amputation with either TMR or standard neurological treatment (SNT). The study also includes an examination of primary versus secondary TMR and explores outcomes in highly comorbid patient populations. A search of central databases was performed, and meta-analysis was completed on extracted data where possible. Eleven studies were identified. Results indicate a significant reduction in PLP and RLP in patients undergoing TMR compared to SNT using various pain scores. TMR also demonstrates improved functional outcomes and decreased opioid use. Furthermore, results indicated patients who underwent TMR at the time of amputation (primary TMR) had improved pain scores compared with those who had TMR performed later (secondary TMR). The review emphasizes the benefits of TMR as a valuable surgical adjunct for amputee patients, while also highlighting the need for further research, especially in comorbid populations.

Patient and procedural characteristics of successful endovascular procedures in the BEST-CLI Trial and their relationship to major adverse limb events

Abstract Background The Best Endovascular versus Best Surgical Therapy in Patients with Chronic Limb Threatening Ischemia (CLTI) (BEST-CLI) trial randomized 1830 subjects with chronic limb threatening ischemia (CLTI) to endovascular or surgical bypass revascularization. Major adverse limb events (MALE) were higher after endovascular revascularization compared to bypass in the cohort with bypass using adequate single segment great saphenous vein. However, 15% of endovascular procedures had a major endpoint due to lack of technical success of the index procedure. Purpose To assess the factors related to a MALE in subjects in the BEST-CLI trial with an initial endovascular procedure that was technically successful. Methods All patients with a technically successful endovascular procedure (defined as a residual stenosis < 50% in the superficial femoral, popliteal, and/ or tibial arteries with in-line flow to the foot) were included. MALE was defined as above ankle amputation of the index limb or a major index-limb reintervention (new bypass, interposition graft revision, thrombectomy, or thrombolysis). Patient, procedure, and limb characteristics at the time of the index procedure were compared to the risk of MALE over an average 2.7 years follow-up. Characteristics were compared with the Kruskal-Wallis or Chi-square tests as appropriate. Results Of 923 patients having endovascular therapy as the index revascularization, 773 (84%) had a technically successful procedure. The cause of failure in 122 (82%) of unsuccessful procedures was the inability to cross the lesion with a wire. Significant patient factors associated with MALE included younger age (64 vs 68 years, p<0.0001), current smoking (44% vs 33%, p=0.004), and end-stage renal disease (17% vs 10%, p=0.013). Diabetes mellitus was not associated with MALE (74% vs 68%, p=0.08). Significant limb characteristics associated with MALE included lesions treated in the superficial femoral (SFA) or above knee popliteal artery (87% vs 81%, p=0.042), length of lesion in the SFA or above knee popliteal artery (201 cm vs 172 cm, p=0.02), use of atherectomy and bare-metal stent (10% vs 5%, p=0.01), and total procedure time (172 vs 155 min, p=0.002). Lesions treated in the below-knee popliteal artery or tibial arteries (62% vs 62%, p=0.93) or lesion length in this region (134 vs 144 cm, p=0.70) were not related to the risk of MALE. Conclusions The risk of MALE after successful endovascular revascularization for CLTI was increased with younger age, current smoking, end-stage renal disease, longer lesion length, treatment of the SFA to above knee popliteal arteries, and treatment with atherectomy with bare-metal stenting. Treatment of below knee lesions were not associated with MALE. These results indicate the importance of both modifiable and non-modifiable patient factors as well as the anatomic location of disease in determining limb outcomes in CLTI.

Unraveling anesthetic challenges of a patient with dilated cardiomyopathy posted for lower limb amputation surgery -A case report

This case report details the anesthetic management of a 64-year-old male with dilated cardiomyopathy (DCM) and a significantly reduced ejection fraction, undergoing lower limb amputation for peripheral arterial disease. Managing anesthesia in such patients poses considerable challenges due to the complexities associated with congestive heart failure. The successful administration of general anesthesia in this case can be attributed to a rigorous preoperative assessment and a meticulously devised anesthetic plan. The systematic approach included careful monitoring, fluid management, and the use of specific anesthetic agents that minimize cardiovascular stress, thereby ensuring an uneventful anesthetic course. This report emphasizes the importance of strategic planning and expert execution in the anesthesia management of patients with severe cardiomyopathy undergoing major surgical procedures.

Carbon dioxide (CO2) as an alternative contrast agent in percutaneous transluminal angioplasty procedures for chronic limb-threatening ischemia patients with chronic kidney disease

Background: Chronic limb-threatening ischemia (CLTI) is a very morbid illness that significantly reduces quality of life. The severity of this disease may necessitate revascularization or amputation. Arteriography is frequently performed for the planning of revascularization. Patients with compromised kidney function need alternative contrast agents. CO2 may be utilized in lower extremity vascular diagnostics and intervention, especially in patients at risk for contrast-induced nephropathy (CIN). Case Illustration: An 80-year-old female with bilateral leg pain and leg swelling had an ulcer on her toe for 2 weeks. She had a history of intermittent claudication for 1 year, hypertension for 5 years, kidney stones for 2 years, and chronic kidney disease for 1 year. She underwent an ECG, laboratory, USG, DUS, and CT-angiography examination. From her laboratory result, her initial creatinine was 5.02 mg/dL (eGFR 8 mL/m/1.73 m2). After good hydration, it became 1.28 mg/dL (eGFR 39 mL/m/1.73 m2). After a CT-angiography procedure, her creatinine level was increased (3.7 mg/dL; eGFR 10.9 mL/m/1.73 m2). She was diagnosed with CLTI Rutherford V Fontain 3 left lower extremity. She suggested doing an angioplasty procedure with a safer contrast agent. An angioplasty procedure was done at RSSA Malang with CO2 contrast. After the procedure, her leg pain improved, and her creatinine didn’t elevate. Conclusion: CO2 angiography might be used as a safe alternative contrast medium in patients with CLTI, which benefits the preservation of renal function and prevents limb amputations. Keyword: chronic limb-threatening, chronic kidney disease, CO2 angiography, contrast-induced nephropathy, peripheral artery disease