Predictors of Delayed Wound Healing after Endovascular Therapy of Isolated Infrapopliteal Lesions Underlying Critical Limb Ischemia in Patients with High Prevalence of Diabetes Mellitus and Hemodialysis

Length and Cost of Hospital Stay in Poor-Risk Patients With Critical Limb Ischemia Undergoing Revascularization

BACKGROUND

The aim of the current study was to identify the distribution of length and cost of hospital stay and their associated risk factors in poor-risk Japanese critical limb ischemia (CLI) patients undergoing revascularization. Methods and Results: We analyzed prospectively collected data from 507 CLI patients who required assistance in their daily lives due to disability in activities of daily living and/or cognitive function impairment and who underwent revascularization. The median length and cost of hospital stay were 23 days (IQR, 9-52 days) and ¥2.25m (IQR, ¥1.33m-3.58m), respectively. Reduced albumin, tissue loss, infection, surgical reconstruction, and bilateral revascularization were associated with prolonged hospital stay (P=0.012, 0.019, <0.001, <0.001, and <0.001, respectively). Doubling the length of the hospital stay was associated with a 44% increase in hospital cost. Regular dialysis, surgical reconstruction, and bilateral revascularization were independently associated with an approximately 20% increase in the cost of hospital stay (all P<0.001).

CONCLUSIONS

Length and cost of hospital stay varied considerably between patients. Low serum albumin, tissue loss, infection, surgical reconstruction, and bilateral revascularization were associated with longer hospital stay. Regular dialysis, surgical reconstruction, and bilateral revascularization were independently associated with an approximately 20% increase in the cost of hospital stay.

Predictors of delayed wound healing after successful isolated below-the-knee endovascular intervention in patients with ischemic foot ulcers

OBJECTIVE

The purpose of this study was to explore the predictors of delayed wound healing and their use in risk stratification for endovascular treatment (EVT) of patients with critical limb ischemia (CLI) due to isolated below-the-knee lesions.

METHODS

Wound healing rates were analyzed retrospectively in patients who underwent successful below-the-knee percutaneous transluminal balloon angioplasty for CLI with tissue loss between May 2008 and June 2013. We also analyzed the independent predictors of delayed wound healing and their use in risk stratification.

RESULTS

The cumulative wound healing rates were 13.9%, 43.8%, 57.7%, and 65.7% at 3, 6, 9, and 12 months, respectively. Multivariate Cox proportional hazards analysis revealed the following as independent predictors of wound nonhealing after initial successful EVT: patients with end-stage renal disease receiving dialysis (hazard ratio [HR], 2.6; 95% confidence interval [CI], 1.0-6.3; P  = .04); albumin level <3.0 g/dL (HR, 2.0; 95% CI, 1.1-3.8; P  = .02); C-reactive protein level >5.0 mg/dL (HR, 3.9; 95% CI, 1.6-9.6; P = .003); major tissue loss (HR, 2.1; 95% CI, 1.3-3.4; P = .003); wound infection (HR, 1.9; 95% CI, 1.2-2.9; P = .005); gangrene (HR, 1.8; 95% CI, 1.2-2.8; P = .008); wound depth (University of Texas grade 3; HR, 3.4; 95% CI, 1.4-8.6; P = .009); duration of ulcer (≥2 months; HR, 2.9; 95% CI, 1.0-8.4; P = .048); insulin use (HR, 1.7; 95% CI, 1.0-2.8; P = .04); and lack of below-the-ankle runoff (HR, 1.9; 95% CI, 1.0-3.4; P = .04).

CONCLUSIONS

The general status of the patient and the target limb's condition are important predictors of wound nonhealing. Regarding the limb's condition, information on wound depth and duration in addition to wound extent and infection would further enable the selection of suitable CLI patients for EVT. Such information would also enable optimal wound management, leading to successful wound healing and improved limb salvage and survival rates.

Risk factors for postoperative complications of orthopedic surgery in patients with hemophilia: Second report

This study was conducted to investigate the incidence in patients with hemophilia of postoperative complications and risk factors for these complications. Overall, 12 (6.5%) patients developed a postoperative infection. There were 6 (3.4%) postoperative surgical site infections. The presence of an inhibitor was the only risk factor for surgical site infection. Risk factors for delayed wound healing were older age, higher preoperative serum albumin level and procedures other than joint replacement or arthroscopy. HIV infection status was not a risk factor for postoperative complications.

Peripheral artery disease is associated with frailty in chronic hemodialysis patients

Objectives

The clinical condition of frailty is a common problem in the elderly population. However, the relationship between peripheral artery disease and frailty in hemodialysis patients remains unknown. The aim of this study was to identify the relationships between peripheral artery disease and frailty in Japanese chronic hemodialysis patients.

Methods

A total of 362 chronic hemodialysis patients who regularly visited six institutions were enrolled. To evaluate frailty, the modified Fried’s frailty phenotype adjusted for Japanese were used. Peripheral artery disease was defined as ankle-brachial index <0.9.

Results

Of 362 patients, 62 patients (17.1%) were categorized as peripheral artery disease group and 300 patients (82.9%) as Non-peripheral artery disease group. The prevalence of frailty in the peripheral artery disease group was significantly higher than in the Non-peripheral artery disease group (34% vs. 18%, P = 0.0103). Non-shunt side grip strength was significantly stronger in the Non-peripheral artery disease group (23.6 kg vs. 17.0 kg, P < 0.0001). Thigh circumferences were also significantly larger in the Non-peripheral artery disease group (41.7 cm vs. 39.7 cm, P = 0.0054). A multivariate logistic regression analysis demonstrated that the factors independently associated with peripheral artery disease were as follows: frailty (odds ratio = 2.06, 95% confidence interval 1.09–3.89) and myocardial infarction (odds ratio = 3.74, 95% confidence interval 2.05–6.83).

Conclusions

It is concluded that peripheral artery disease is closely associated with frailty in hemodialysis patients.

Wound Blush Obtainment Is the Most Important Angiographic Endpoint for Wound Healing

OBJECTIVES

This study aimed to assess the optimal angiographic endpoint of endovascular therapy (EVT) for wound healing.

BACKGROUND

Several reports have demonstrated acceptable patency and limb salvage rates following infrapopliteal interventions for the treatment of critical limb ischemia (CLI). However, the optimal angiographic endpoint of EVT remains unclear.

METHODS

We conducted a subanalysis of the prospective multicenter OLIVE (Endovascular Treatment for Infrainguinal Vessels in Patients with Critical Limb Ischemia) registry investigation assessing patients who received infrainguinal EVT for CLI. We analyzed data from 185 limbs with ischemic ulcerations classified as Rutherford class 5 or 6, managed with EVT alone (i.e., not undergoing bypass surgery). The wound healing rate after EVT was estimated by the Kaplan-Meier method. The association between final angiographic data and wound healing was assessed employing a Cox proportional hazards model.

RESULTS

The overall wound healing rate was 73.5%. The probabilities of wound healing in patients with wound blush obtainment was significantly higher than that of those without wound blush (79.6% vs. 46.5%; p = 0.01). In the multivariate analysis, wound blush obtainment was an independent predictor of wound healing.

CONCLUSION

The presence of wound blush after EVT is significantly associated with wound healing. Wound blush as an angiographic endpoint for EVT may serve as a novel predictor of wound healing in patients with CLI.

Analysis of wound healing time and wound-free period as outcomes after surgical and endovascular revascularization for critical lower limb ischemia

BACKGROUND

Traditional end points, such as amputation-free survival, used to assess the clinical effectiveness of lower limb revascularization have shortcomings because they do not account independently for wound nonhealing and recurrence or patient survival. Wound healing process and maintenance of a wound-free state after revascularization were not well-studied. The aim of this study was to elucidate the long-term clinical course of ischemic wounds after revascularization. We focused on initial wound healing process as well as the maintenance of a wound-free state after achievement of wound healing. We introduced a wound-free period (WFP; the period during which limbs maintained an ulcer-free state) and Wound Recurrence and Amputation-free Survival (WRAFS) as parameters and tested their effectiveness in evaluating clinical outcomes of limbs treated using endovascular therapy (EVT) and surgical revascularization.

METHODS

The medical records of patients developing lower critical limb ischemia with tissue loss who underwent surgical or endovascular revascularization of the infrainguinal vessels between 2009 and 2013 were reviewed retrospectively. The risk factors for achieving wound healing and WRAFS were analyzed using Kaplan-Meier survival curves and Cox regression model. Risk factors to prolong wound healing time (WHT) and reduce WFP were determined by the least squares method.

RESULTS

In total, 233 patients underwent 278 limb revascularizations; 138 endovascular and 140 surgical procedures were performed as first treatments. The proportion of healed wounds 1, 2, and 3 years after primary revascularization was 64.0%, 69.7%, and 70.5%, respectively. Significant risk factors for wound healing were an EVT-first strategy (risk ratio [RR], 2.47), congestive heart failure (RR, 2.05), and wound, ischemia, and foot infection wound grade (RR, 1.59). The mean WHT was 143.7 days. An EVT-first strategy and wound infection contributed to significantly longer WHT. The mean WFP was 711.0 days. An EVT-first strategy, history of coronary artery disease, and dialysis dependence were associated with significantly shorter WFPs. WRAFS at 1 and 2 years after achievement of wound healing were 76.9% and 64.2%, respectively. Significant risk factors against WRAFS were a history of coronary artery disease (RR, 1.68), dialysis dependence (RR, 2.03), and being wheel chair bound (RR, 1.64).

CONCLUSIONS

EVT revascularization was associated with longer WHT, reduced wound healing rate, and a shorter WFP compared with surgical revascularization. wound, ischemia, and foot infection grade was associated with longer WHT and reduced wound healing rate, but not associated with a shorter WFP. Systemic conditions such as dialysis dependence, congestive heart failure, and being wheel chair bound were associated with reduced wound healing rate and shorter WFP, presumably because they limited life expectancy. WHT and WFP are useful criteria for evaluating limb outcomes in patients with critical limb ischemia.

Clinical Outcomes of Pedal Artery Angioplasty for Patients With Ischemic Wounds: Results From the Multicenter RENDEZVOUS Registry

OBJECTIVES

The aim of this study was to investigate the clinical outcomes of pedal artery angioplasty (PAA) for patients with critical limb ischemia.

BACKGROUND

Pedal artery disease is considered a predictor of delayed wound healing (DH) after endovascular therapy. Adjunctive PAA might improve the speed and extent of wound healing.

METHODS

Consecutive patients with critical limb ischemia (n = 257) presenting with de novo infrapopliteal and pedal artery disease were retrospectively reviewed from a multicenter registry. Patients were divided into 2 groups according to whether PAA was performed (n = 140) or not (n = 117). The rate of wound healing and time to wound healing were compared between these groups. DH score was calculated using the number of independent predictors of DH. Patients were stratified into 3 groups according to DH score: low risk (DH score = 0), moderate risk (DH score = 1 or 2), and high risk (DH score = 3). Estimated efficacy was analyzed for each risk-stratified population.

RESULTS

The rate of wound healing was significantly higher (57.5% vs. 37.3%, p = 0.003) and time to wound healing significantly shorter (211 days vs. 365 days; p = 0.008) in the PAA group. In a multivariate analysis, nonambulatory status, target wound depth (UT grade ≥2), and daily hemodialysis were revealed as predictors of DH. In the moderate-risk population, adjunctive PAA significantly improved the rate of wound healing (59.3% vs. 33.9%; p = 0.001). In the high-risk population, however, PAA did not affect wound healing.

CONCLUSIONS

Patients who underwent PAA showed a higher rate of wound healing and shorter time to wound healing, especially in the moderate-risk population. With regard to wound healing, this aggressive strategy might become a salvage procedure for patients with critical limb ischemia presenting with pedal artery disease.

Hypoalbuminemia is a predictor of mortality and rebleeding in peptic ulcer bleeding under proton pump inhibitor use

BACKGROUND/PURPOSE

Peptic ulcer bleeding remains a deadly disease, and a simple indicator of long-term outcomes is crucial. This study validated whether hypoalbuminemia and its related factors in patients with peptic ulcer bleeding can indicate long-term mortality and rebleeding under proton pump inhibitor use.

METHODS

The prospective cohort study enrolled 426 patients with peptic ulcer bleeding who had high risk stigmata at endoscopy and had received endoscopic hemostasis. They were divided into 79 patients in the hypoalbuminemia group (Hypo-AG, serum albumin <28 g/L), 135 in the marginal hypoalbuminemia group (Margin-AG, serum albumin 28-34.9 g/L), and 212 in the normal albuminemia group (Normal-AG, serum albumin ≥35 g/L). Each subject received 72-h of intravenous infusion and then the oral form of proton pump inhibitors and were monitored for 84 days to assess all-cause mortality and recurrent bleeding.

RESULTS

The primary outcome of all-cause mortality rates were increased in a stepwise fashion in a trend from Normal-AG, Margin-AG, to Hypo-AG (0-28th day: 1.9%, 2.2%, 12.8%, p < 0.001; 29th-84th day: 2.5%, 8.0%, 10.6%, p < 0.01). The secondary outcome of recurrent bleeding rates were also increased in the same fashion (0-28th day: 6.4%, 15.4%, 24.6%, p < 0.001; 29th-84th day: 0%, 3.0%, 4.2%, p = 0.01). Abnormal albuminemia was <30 g/L related to hemoglobin levels <70 g/L, nosocomial bleeding, cirrhosis, age ≥70 years, shock, and ulcer size ≥1.0 cm independently (p < 0.05).

CONCLUSION

Hypoalbuminemia in patients with peptic ulcer bleeding can be an alarm indicator of all-cause mortality and recurrent bleeding in a long-term follow-up situation under proton pump inhibitor use (NCT01591083).

Angiosome-directed revascularization in patients with critical limb ischemia

OBJECTIVE

Direct revascularization (DR), according to the angiosome concept, provides direct blood flow to the site of tissue loss in patients with critical limb ischemia (CLI). DR may lead to improved outcomes; however, evidence for this is controversial. This systematic review and meta-analysis investigated the outcomes of surgical and endovascular DR compared with indirect revascularization (IR) in patients with CLI.

METHODS

A systematic review was undertaken using the Cochrane Collaboration specified tool, and a meta-analysis was done according to the MOOSE (Meta-analysis of Observational Studies in Epidemiology) criteria. The electronic databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched for studies of DR compared with IR in patients with CLI with tissue loss. All articles were critically assessed for relevance, validity, and availability of data regarding patient and lesion characteristics and outcomes. When possible, data were systematically pooled, and a meta-analysis was performed for wound healing, major amputation, amputation-free survival, and overall survival.

RESULTS

Of 306 screened abstracts, 19 cohort studies with 3932 patients were included. Nine scored 7 or higher on the Newcastle-Ottawa score. DR significantly improved wound healing (risk ratio [RR], 0.60; 95% confidence interval [CI], 0.51-0.71), major amputation (RR, 0.56; 95% CI, 0.47-0.67), and amputation-free survival rates (RR, 0.83; 95% CI, 0.69-1.00) compared with IR. This significance was lost in major amputation on sensitivity analysis for bypass studies. No significant difference was found in overall survival. In studies stratifying for collaterals, no differences between DR and IR were found in wound healing or major amputations in the presence of collaterals.

CONCLUSIONS

DR significantly improves wound healing and major amputation rates after endovascular treatment in patients with CLI, supporting the angiosome theory. In the presence of collaterals, outcomes after IR are similar to outcomes after DR. Alternatively, patients without collaterals may benefit even more from DR as a primary treatment strategy. The angiosome theory is less applicable in bypass surgery, because bypasses are generally anastomosed to the least affected artery, with runoff passing the ankle to maintain bypass patency.

Aggressive Wound Care by a Multidisciplinary Team Improves Wound Healing after Infrainguinal Bypass in Patients with Critical Limb Ischemia

BACKGROUND

A long period is generally required for ischemic ulcer to heal after revascularization. The strategy of postoperative wound care can affect wound healing. This study was conducted to investigate the degree to which aggressive wound care (AWC) by a team of multidisciplinary specialists actually shortens the time to wound healing and increases the rate of wound healing in limbs undergoing surgical bypass for ischemic tissue loss in a real clinical setting.

METHODS

A total of consecutive 126 patients undergoing infrainguinal bypass for tissue loss from April 2011 to March 2015 were reviewed. Prior to March 2013, standard wound care (SWC) including typical daily dressing change with disinfection and irrigation, occasional surgical debridement, and negative pressure wound therapy (when necessary) was performed by vascular surgeons. Thereafter, in addition to SWC, AWC including intense daily bedside surgical debridement under a sciatic nerve block by an anesthesiologist and active skin grafting by a dermatologist, if necessary, was performed. Wound healing and major amputation were defined as the end points. The 1-year outcomes of the 2 groups were calculated using the Kaplan-Meier method and compared, and the significant predictors of each outcome were determined by a Cox proportional hazards analysis.

RESULTS

The wound healing of the AWC group was superior to that of the SWC group (AWC versus SWC, 1-year wound healing rate: 92% vs. 80%; mean wound healing time: 48 days vs. 82 days; P = 0.011), and no significant difference between the 2 regimens in the freedom from major amputation was observed. AWC, Rutherford 5, no wound infection, normal serum albumin, direct angiosome, and cilostazol use were significant predictors of wound healing, and female gender and no cilostazol use were significant predictors of major amputation by a multivariate analysis.

CONCLUSIONS

Aggressive wound care by the team consisting of multidisciplinary specialists remarkably shortened the time to wound healing and increased the rate of wound healing within 1 year.

Retrograde Approach Using Surgical Cutdown Technique for Limb Salvage in a Case of Critical Limb Ischemia With Severely Calcified Tibial Occlusive Disease

We here report a successful angioplasty for tibial artery occlusion using direct tibial puncture and subsequent retrograde approach under surgical cutdown technique. An 82-year-old man with ulcer/gangrene in first and second digits was referred to our hospital for endovascular therapy (EVT) of lower extremity ischemia. Diagnostic angiogram revealed anterior tibial artery (ATA) occlusion with severe calcification. Subintimal angioplasty was attempted using a 0.014-inch hydrophilic guidewire but was unsuccessful. A retrograde approach was subsequently attempted for ATA recanalization. However, because of severe calcification of dorsal pedis artery (DPA), percutaneous distal puncture was also unsuccessful. Direct puncture under surgical cutdown technique for DPA was subsequently performed and was successful. A 0.014-inch hydrophilic wire was advanced in retrograde fashion across the ATA occlusion and was used to access the microcatheter positioned at the proximal ATA via antegrade approach. Angioplasty of the ATA occlusion was performed using a 2.5-/3.0-mm tapered balloon. Completion angiogram revealed restoration of flow without dissection. Skin perfusion pressure was dramatically improved. Complete wound healing was achieved 5 months after EVT.