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Braet DJ, Pourak K, Delbono L, Powell C, Smith ME, Schechtman D, Obi AT, Coleman DM, Corriere MA. Comparative evaluation of transcutaneous oxygen tension and ankle-brachial index as predictors of reoperation following below-knee amputation. J Vasc Surg 2024; 80:223-231.e2. [PMID: 38431062 DOI: 10.1016/j.jvs.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/13/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Decision-making regarding level of lower extremity amputation is sometimes challenging. Selecting an appropriate anatomic level for major amputation requires consideration of tradeoffs between postoperative function and risk of wound complications that may require additional operations, including debridement and/or conversion to above-knee amputation (AKA). We evaluated the utility of common, non-invasive diagnostic tests used in clinical practice to predict the need for reoperations among patients undergoing primary, elective, below knee-amputations (BKAs) by vascular surgeons. METHODS Patients undergoing elective BKA over a 5-year period were identified using Current Procedural Terminology codes. Medical records were reviewed to characterize demographics, pre-amputation testing transcutaneous oxygen tension (TcPO2), and ankle-brachial index (ABI). The need for ipsilateral post-BKA reoperation (including BKA revision and/or conversion to AKA) regardless of indication was the primary outcome. Associations were evaluated using univariable and multivariable logistic regression models. Cutpoints for TcPO2 values associated with amputation reoperation were evaluated using receiver operating characteristic curves. RESULTS We identified 175 BKAs, of which 46 (26.3%) required ipsilateral reoperation (18.9% BKA revisions and 14.3% conversions to AKA). The mean age was 63.3 ± 14.8 years. Most patients were male (65.1%) and White (72.0%). Mean pre-amputation calf TcPO2 was 40.0 ± 20.5 mmHg, and mean ABI was 0.64 ± 0.45. In univariable models, post-BKA reoperation was associated with calf TcPO2 (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.94-0.99; P = .013) but not ABI (OR, 0.53; 95% CI, 0.19-1.46; P = .217). Univariable associations with reoperation were also identified for age (OR, 0.97; 95% CI, 0.94-0.990; P = .003) and diabetes (OR, 0.43; 95% CI, 0.21-0.87; P = .019). No associations with amputation revision were identified for gender, race, end-stage renal disease, or preoperative antibiotics. Calf TcPO2 remained associated with post-BKA reoperation in a multivariable model (OR, 0.97; 95% CI, 0.94-0.99; P = .022) adjusted for age (OR, 0.98; 95% CI, 0.94-1.01; P = .222) and diabetes (OR, 0.98; 95% CI, 0.94-1.01; P = .559). Receiver operating characteristic analysis suggested a TcPO2 ≥38 mmHg as an appropriate cut-point for assessing risk for BKA revision (area under the curve = 0.682; negative predictive value, 0.91). CONCLUSIONS Reoperation after BKA is common, and reoperation risk was associated with pre-amputation TcPO2. For patients undergoing elective BKA, higher risk of reoperation should be discussed with patients with an ipsilateral TcPO2 <38 mmHg.
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Affiliation(s)
- Drew J Braet
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI.
| | - Kian Pourak
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Luciano Delbono
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Chloe Powell
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Margaret E Smith
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - David Schechtman
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Andrea T Obi
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Dawn M Coleman
- Department of Surgery, Division of Vascular Surgery, Duke University School of Medicine, Durham, NC
| | - Matthew A Corriere
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
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Tai TY, Lin KJ, Chang HY, Wu YC, Huang CU, Lin XY, Tsai FC, Tsai CS, Chen YH, Wang FY, Chang SC. Early identification of delayed wound healing in complex diabetic foot ulcers treated with a dermal regeneration template: a novel clinical target and its risk factors. Int J Surg 2024; 110:943-955. [PMID: 38085826 PMCID: PMC10871583 DOI: 10.1097/js9.0000000000000898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/02/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND The dermal regeneration template (DRT), a tissue-engineered skin substitute composing a permanent dermal matrix and an upper temporary silicone layer that serves as the epidermis, has demonstrated efficacy in treating uncomplicated diabetic foot ulcers (DFUs). Our institution has obtained good outcomes with DRT in patients with more complicated DFUs. Because of its chronicity, the authors are working to identify a clinical target that anticipates delayed healing early in the treatment in addition to determining the risk factors linked to this endpoint to increase prevention. MATERIALS AND METHODS This retrospective single-center study analyzed patients with DFUs who underwent wound reconstruction using DRT between 2016 and 2021. The patients were categorized into poor or good graft-take groups based on their DRT status on the 21st day after the application. Their relationship with complete healing (CH) rate at day 180 was analyzed. Variables were collected for risk factors for poor graft take at day 21. Independent risk factors were identified after multivariable analysis. The causes of poor graft take were also reported. RESULTS This study examined 80 patients (38 and 42 patients in the poor and good graft-take groups, respectively). On day 180, the CH rate was 86.3% overall, but the poor graft-take group had a significantly lower CH rate (76.3 vs. 95.2%, P =0.021) than the good graft-take group. Our analysis identified four independent risk factors: transcutaneous oxygen pressure less than 30 mmHg (odds ratio, 154.14), off-loading device usage (0.03), diabetic neuropathy (6.51), and toe wound (0.20). The most frequent cause of poor graft take was infection (44.7%), followed by vascular compromise (21.1%) and hematoma (15.8%). CONCLUSION Our study introduces the novel concept of poor graft take at day 21 associated with delayed wound healing. Four independent risk factors were identified, which allows physicians to arrange interventions to mitigate their effects or select patients more precisely. DRT represents a viable alternative to address DFUs, even in complicated wounds. A subsequent split-thickness skin graft is not always necessary to achieve CH.
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Affiliation(s)
- Ting-Yu Tai
- Division of Cardiovascular Surgery, Heart Center, Cheng Hsin General Hospital
| | - Kuan-Jie Lin
- Division of Cardiovascular Surgery, Department of Surgery, Shuang-Ho Hospital
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University
| | - Hao-Yun Chang
- Department of Medical Education, Division of General Medicine, Far Eastern Memorial Hospital
| | - Yi-Chun Wu
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ching-Uen Huang
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
| | - Xin-Yi Lin
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
| | - Feng-Chou Tsai
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
| | - Ching-Sung Tsai
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
| | - Yu-Han Chen
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
| | | | - Shun-Cheng Chang
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University
- Division of Plastic Surgery, Integrated Burn and Wound Care Center, Department of Surgery, Shuang-Ho Hospital
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3
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Troisi N, Bertagna G, Juszczak M, Canovaro F, Torri L, Adami D, Berchiolli R. Emergent management of diabetic foot problems in the modern era: Improving outcomes. Semin Vasc Surg 2023; 36:224-233. [PMID: 37330236 DOI: 10.1053/j.semvascsurg.2023.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 06/19/2023]
Abstract
Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Van Den Hoven P, Osterkamp J, Nerup N, Svendsen MBS, Vahrmeijer A, Van Der Vorst JR, Achiam MP. Quantitative perfusion assessment using indocyanine green during surgery - current applications and recommendations for future use. Langenbecks Arch Surg 2023; 408:67. [PMID: 36700999 PMCID: PMC9879827 DOI: 10.1007/s00423-023-02780-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 12/12/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE Incorrect assessment of tissue perfusion carries a significant risk of complications in surgery. The use of near-infrared (NIR) fluorescence imaging with Indocyanine Green (ICG) presents a possible solution. However, only through quantification of the fluorescence signal can an objective and reproducible evaluation of tissue perfusion be obtained. This narrative review aims to provide an overview of the available quantification methods for perfusion assessment using ICG NIR fluorescence imaging and to present an overview of current clinically utilized software implementations. METHODS PubMed was searched for clinical studies on the quantification of ICG NIR fluorescence imaging to assess tissue perfusion. Data on the utilized camera systems and performed methods of quantification were collected. RESULTS Eleven software programs for quantifying tissue perfusion using ICG NIR fluorescence imaging were identified. Five of the 11 programs have been described in three or more clinical studies, including Flow® 800, ROIs Software, IC Calc, SPY-Q™, and the Quest Research Framework®. In addition, applying normalization to fluorescence intensity analysis was described for two software programs. CONCLUSION Several systems or software solutions provide a quantification of ICG fluorescence; however, intraoperative applications are scarce and quantification methods vary abundantly. In the widespread search for reliable quantification of perfusion with ICG NIR fluorescence imaging, standardization of quantification methods and data acquisition is essential.
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Affiliation(s)
- P Van Den Hoven
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - J Osterkamp
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
| | - N Nerup
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
| | - M B S Svendsen
- CAMES Engineering, Copenhagen Academy for Medical Education and Simulation, Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
| | - Alexander Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - J R Van Der Vorst
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, The Capital Region of Denmark, Copenhagen, Denmark
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Hines A, Butterfield R, Boudreaux B, Bhullar P, Severson KJ, McBane RD, Davis MDP, Pittelkow MR, Mangold AR, Alavi A. Characteristics of ulcerated and non‐ulcerated necrobiosis lipoidica. Int J Dermatol 2022; 62:790-796. [PMID: 36479693 DOI: 10.1111/ijd.16529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/30/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Necrobiosis lipoidica (NL) is complicated by ulceration in up to 35% of cases. METHODS Retrospective study of patients with NL seen at our institution between January 1, 1992, and May 25, 2021, was conducted. Ulcerated NL (UNL, n = 83) and non-ulcerated NL (NUNL, n = 233) groups were compared. RESULTS Twenty-six percent (83/316) of patients with NL experienced ulceration. UNL was significantly more likely to be painful (52% vs. 36%, P = 0.01), was more likely to have a lesion-associated cutaneous malignancy (7% vs. 0%, P < 0.001), and had a larger median size (7 vs. 5 cm, P = 0.004) compared to NUNL. Vascular studies were performed on a subset of patients and revealed transcutaneous oxygen pressure (TcPO2) < 40 mm Hg in 53% and venous insufficiency in 62% with no significant differences between UNL and NUNL groups. In patients with unilateral ulceration, mean TcPO2 values (39.7 vs. 46.6 mm Hg), regional perfusion index <0.6 (29% vs. 14%), and TcPO2 < 40 mm Hg (43% vs. 14%) were worse in the ulcerated leg compared to the non-ulcerated leg, but these differences were not statistically significant. CONCLUSIONS UNL was more likely to be painful, develop lesion-associated malignancy, and be larger in size compared to NUNL. There were no statistically significant differences in venous insufficiency, arterial Doppler/ankle brachial index, or TcPO2 values between UNL and NUNL patients, however, a significant portion of the cohort demonstrated abnormal vascular studies, particularly on TcPO2 and venous insufficiency testing.
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Affiliation(s)
| | | | | | | | | | - Robert D. McBane
- Division of Vascular Medicine of Cardiovascular Diseases Mayo Clinic Rochester MN USA
| | | | | | | | - Afsaneh Alavi
- Department of Dermatology Mayo Clinic Rochester MN USA
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7
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Berli MC. Mid- and Hindfoot Amputations in Diabetic Patients. Foot Ankle Clin 2022; 27:687-700. [PMID: 36096559 DOI: 10.1016/j.fcl.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Several surgical options exist to avoid or at least to delay a below-the-knee amputation (BKA). These are the so-called mid- or hindfoot amputations. They are a valuable treatment option in order to maintain the ability to ambulate without major auxiliary means (eg, a prosthesis). Hence, these amputations allow the patients to maintain certain autonomy. The acceptance of these amputations is significantly higher than a BKA, as the body image is less disturbed. The complication rate in hindfoot amputations in diabetic patients is high due to the comorbidities, in particular peripheral arterial disease and polyneuropathy.
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Affiliation(s)
- Martin C Berli
- Division of Technical Orthopaedics, Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland; Universitätsklinik Balgrist, Forchstrasse 340, 8008 Zurich, Switzerland.
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8
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Goodeill T, Than J, Pipitone O, Lin J, Tedesco N. Effects of Hypercarbia on Lower Extremity Primary Total Joint Replacement Infections. Cureus 2022; 14:e26069. [PMID: 35865438 PMCID: PMC9293259 DOI: 10.7759/cureus.26069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Prosthetic joint infection (PJI) is a serious complication after total joint replacement (TJR). Adequate wound oxygenation is critical for wound healing and infection prevention. As carbon dioxide (CO2) is exchanged for oxygen (O2) in the lungs, serum bicarbonate (HCO3-) may be used as a marker for predicting relative serum O2 levels, and therefore, healing potential. No currently published literature explores the relationship between serum bicarbonate levels and PJI in TJR patients. Methods: We performed this retrospective review of lower extremity TJR patients to determine whether the risk of PJI and wound complications within one year was correlated with hypercarbia, which was defined as a preoperative serum bicarbonate level >30 mEq/L. Results: Out of 1,690 TJR procedures, 1.6% (N=27) had a PJI or superficial wound infection within one year postoperatively. The average preoperative serum bicarbonate was 26.9 (SD 2.6) among patients without PJI and 27.2 (SD 2.1) among patients with PJI (p=0.46). Hypercarbia was present in 9.2% of non-PJI patients and in 7.4% of PJI patients. The relative risk of PJI and wound complications did not differ for patients with vs without hypercarbia (RR = 0.79, 95% CI = 0.19-3.31, p=0.75). Conclusion: The results of this study provide preliminary evidence that preoperative hypercarbia may not be correlated with an increase in the risk of PJI or wound complications. However, due to the rarity of both PJI and hypercarbia, a larger patient population is needed to ensure adequate power to detect clinically meaningful effect sizes.
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Does socket liner material affect clinical outcomes in lower limb prosthesis users? Insights from a randomized control trial. Prosthet Orthot Int 2022; 46:199-201. [PMID: 35085177 DOI: 10.1097/pxr.0000000000000092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
Among the noted disadvantages of prosthesis suspension by flexible liner is the increased rate of perspiration within the socket, which has the potential to cause discomfort, suspension issues, and tissue damage. In recent years, phase change material technology has been adopted for the use in prosthesis liners. These promise to improve temperature control and, consequently, reduce sweating. Previous work has demonstrated that this approach is effective in slowing the temperature increase at the limb-socket interface, but it was not clear how this would translate to clinical outcomes. This study had the aim to compare conventional and phase change material liners regarding prosthesis utilization, physical performance, and patient-reported outcome measures. A randomized double-blind cross-over study design with 6-month intervention periods was used. Of the 42 enrolled participants, only 50% completed the protocol. The high attrition was in large part because of the COVID-19 pandemic that started disrupting daily life and thereby the data collection midway through the study period. The findings indicate that the temperature control liners were, by trend, associated with better prosthesis utilization. The found effects did not reach the level of statistical significance, which is likely a result of the unduly reduced sample size.
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10
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Ifergan G, Autret G, Del Giudice C, Lecler A, Lalot A, Marijon C, Casanova A, Perez-Liva M, Bellamy V, Bruneval P, Clement O, Sapoval M, Menasché P, Balvay D. Dynamic contrast enhanced - MRI efficiency in detecting embolization-induced perfusion defects in a rabbit model of critical-limb-ischemia. Magn Reson Imaging 2022; 87:88-96. [PMID: 35026346 DOI: 10.1016/j.mri.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/21/2021] [Accepted: 01/04/2022] [Indexed: 10/19/2022]
Abstract
Critical limb ischemia (CLI) is a severe disease which affects about 2 million people in the US. Its prevalence is assessed at 800/100,000 population. However, no reliable tools are currently available to assess perfusion defects at the muscle tissue level. DCE-MRI is a technique that holds the potential to be effective in achieving this goal. However, preclinical studies performed with DCE-MRI have indicated low sensitivity assessing perfusion at resting state. To improve these previous results, in this work we propose new methodologies for data acquisition and analysis and we also revisit the biological model used for evaluation. Eleven rabbits underwent embolization of a lower limb. They were imaged at day 7 after embolization using DCE-MRI, performed on a 4.7 T small imaging device. Among them, n = 4 rabbits were used for MRI sequence optimization and n = 6 for data analysis after one exclusion. Normalized Areas under the curve (AUCn), and kinetic parameters such as Ktrans and Vd resulting from the Tofts-Kety modeling (KTM) were calculated on the embolized and contralateral limbs. Average and heterogeneity features, consisting on standard-deviation and quantiles, were calculated on muscle groups and whole limbs. The Wilcoxon and Fisher-tests were performed to compare embolized and contralateral regions of interests. The Wilcoxon test was also used to compare features of parametric maps. Quantiles of 5 and 95% in the contralateral side were used to define low and high outliers. A P-value <0.05 was considered statistically significant. Average features were inefficient to identify injured muscles, in agreement with the low sensitivity of the technique previously reported by the literature. However, these findings were dramatically improved by the use of additional heterogeneity features (97% of total accuracy for group muscles, P < 0.01 and 100% of total accuracy for the total limbs). The mapping analysis and automatic outlier detection quantification improvement was explained by the presence of local hyperemia that impair the average calculations. The analysis with KTM did not provide any additional information compared to AUCn. The DCE technique can be effective in detecting embolization-induced disorders of limb muscles in a CLI model when heterogeneity is taken into account in the data processing, even without vascular stimulation. The simultaneous presence of areas of ischemia and hyperemia appeared as a signature of the injured limbs. These areas seem to reflect the simultaneous presence of infarcted areas and viable peripheral areas, characterized by a vascular response that is visible in DCE.
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Affiliation(s)
- Gabriel Ifergan
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
| | - Gwennhael Autret
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
| | - Costantino Del Giudice
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Interventional Radiology / Radiology / Anatomy Pathology /horacic and cardiovascular surgery, Hôpital Européen Georges Pompidou, APHP, France.
| | - Augustin Lecler
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Fondation Ophtalmologique Adolphe de Rothschild, France.
| | - Adrien Lalot
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France
| | - Camille Marijon
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
| | - Amaury Casanova
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France
| | - Mailyn Perez-Liva
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
| | - Valérie Bellamy
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
| | - Patrick Bruneval
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Interventional Radiology / Radiology / Anatomy Pathology /horacic and cardiovascular surgery, Hôpital Européen Georges Pompidou, APHP, France.
| | - Olivier Clement
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Interventional Radiology / Radiology / Anatomy Pathology /horacic and cardiovascular surgery, Hôpital Européen Georges Pompidou, APHP, France.
| | - Marc Sapoval
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Interventional Radiology / Radiology / Anatomy Pathology /horacic and cardiovascular surgery, Hôpital Européen Georges Pompidou, APHP, France.
| | - Philippe Menasché
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France; Interventional Radiology / Radiology / Anatomy Pathology /horacic and cardiovascular surgery, Hôpital Européen Georges Pompidou, APHP, France.
| | - Daniel Balvay
- Regenerative Therapies for Cardiac and Vascular Diseases / In vivo Imaging Research / Integrative Epidemiology of Cardiovascular diseases, Université de PARIS, PARCC U970, INSERM, France.
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11
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Lindberg JW. Predicting Clinical Outcomes in a Diabetic Foot Ulcer Population Using Fluorescence Imaging. Adv Skin Wound Care 2021; 34:596-601. [PMID: 34669662 DOI: 10.1097/01.asw.0000792920.34104.83] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To retrospectively evaluate a cohort of patients with diabetic foot ulcers to determine if the rate of microcirculatory flow detected by fluorescence imaging within the wound and surrounding tissue is associated with healing outcomes. METHODS Tissue perfusion parameters used for the current analysis were the ingress rate (IR) within the wound bed (R01) and in an area remote from the wound (REF), as well as time to first blush. Wounds were then categorized based on their outcome (healed, healing, chronic nonhealing, partial foot amputation, proximal amputation below the knee) and compared between patients with positive or negative wound healing outcomes. RESULTS The final study cohort included 61 wounds and demonstrated that a higher IR within R01 and REF areas was significantly associated with positive outcomes, whereas time to first blush was not. A two-predictor logistic model found a significant relationship between IR (R01 and REF) and odds of wound healing. CONCLUSIONS Fluorescence imaging evaluation of a diabetic foot ulcer can provide valuable information on healing outcomes that can help determine if a wound is progressing toward healing and therefore may help inform the need for advanced wound modalities, referrals, and amputation.
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Affiliation(s)
- John W Lindberg
- John W. Lindberg, MD, CWSP, is Medical Director, Emanate Health Wound Center, Covina, California. Acknowledgment: Medical writing support was provided by Jordanna Bermack, PhD. Stryker provided funding to support limited study costs. The author has disclosed no other financial relationships related to this article. Submitted November 3, 2020; accepted in revised form January 26, 2021
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12
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Gao L, Li T, Wang S, Wang J. Successful application of extracorporeal circulation compression perfusion in the treatment of diabetic foot: a retrospective cross-sectional study. J Int Med Res 2021; 49:3000605211053235. [PMID: 34686093 PMCID: PMC8544771 DOI: 10.1177/03000605211053235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To investigate the clinical effect of extracorporeal circulation compression perfusion (ECCP) in the treatment of diabetic foot. METHODS We retrospectively evaluated 89 patients with diabetic foot admitted from January 2017 to April 2019. The patients were grouped according to whether they received ECCP treatment; experimental group: 27 patients, controls: 62 patients. After applying the inclusion criteria and exclusion criteria, there were 21 patients in the experimental group and 21 patients in the control group. Foot microcirculation was evaluated by measuring the percutaneous oxygen partial pressure (TcPO2) and infrared thermography (IRT). Wound healing time and ulcer recurrence rate 1 year after discharge were compared between the groups. RESULTS TcPO2 and IRT values in the experimental group differed significantly compared with the control group. Foot ulcer healing time in the experimental group was shorter than that in the control group (17.10 ± 3.08 days vs 25.38 ± 4.40 days, respectively), and the recurrence rate after 1 year in the experimental group was lower than that in the control group (2/21, 9.5% vs 9/21, 42.8%, respectively). CONCLUSION ECCP improved foot microcirculatory perfusion in diabetic foot treatment. ECCP has clinical practicality and may accelerate wound healing speed and reduce ulcer recurrence.
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Affiliation(s)
- Lei Gao
- Capital Medical University Affiliated Beijing Shijitan Hospital, Orthopedic Department, 117968Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Tianbo Li
- Capital Medical University Affiliated Beijing Shijitan Hospital, Orthopedic Department, 117968Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Shuo Wang
- Capital Medical University Affiliated Beijing Shijitan Hospital, Orthopedic Department, 117968Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Jiangning Wang
- Capital Medical University Affiliated Beijing Shijitan Hospital, Orthopedic Department, 117968Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
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13
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Meyer A, Yagshyyev S, Lang W, Rother U. The predictive value of microperfusion assessments for the follow-up of tibial bypass grafts. J Vasc Surg 2021; 75:1008-1013. [PMID: 34600032 DOI: 10.1016/j.jvs.2021.08.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We conducted a prospective evaluation of microperfusion parameters after tibial bypass surgery was performed. Differences between grafts with occlusions during follow-up and patent grafts were analyzed in relation to the pedal arch quality. METHODS Patients receiving tibial bypass grafts for chronic limb-threatening ischemia from 2019 to 2020 were included. Assessment of microcirculation (parameters: hemoglobin oxygen saturation [sO2] and flow) was done by laser Doppler flowmetry and white light spectrometry (oxygen-to-see), supine and in elevation, whereas the macrocirculation was evaluated by the ankle-brachial index and duplex ultrasound examination. The quality of run-off was graded for each patient. Measurements were performed preoperatively, 1 day postoperatively, and after 6 months. Patients with graft occlusions during follow-up (OCCLUDED) and patients without occlusions (OPEN) were compared. RESULTS We included 42 patients (13 women, 29 men; mean age, 76.1 years; range, 60-89 years) were included. The patency of all grafts 1 day after the operation was confirmed by ultrasound examination. The overall analysis of the microcirculation showed significant changes in both the supine and elevated leg position between measurements taken preoperatively, 1 day after the operation, and after 6 months for the parameters sO2 and FLOW (sO2 supine, P = .001; sO2 elevated, P < .001; FLOW supine, P < .001; FLOW elevated, P < .001). The comparison of the values 1 day after the operation yielded significantly decreased microperfusion parameters (both O2 and FLOW) in the group that developed bypass occlusion in the later follow-up period (sO2 supine: OCCLUDED, 35.7% [7.3-65.0] and OPEN, 48.7% [25.0-72.3] P = .011; FLOW supine: OCCLUDED, 27.7 A.U. [12.7-52.7] and OPEN, 57.3 A.U. [16.0-106.7], P = .008). No significant differences in the severity of the arch impairment was found between the OPEN and OCCLUDED groups (P = .651). Absolute values of the parameters sO2 and flow showed no correlation with the pedal arch classification. CONCLUSIONS Significantly poorer microperfusion was detected postoperatively in patients with later occurrence of graft occlusions despite patent grafts on the first postoperative day. Microperfusion measurements might be a possible tool for the prediction of graft failure.
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Affiliation(s)
- Alexander Meyer
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany.
| | - Shatlyk Yagshyyev
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Werner Lang
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ulrich Rother
- Department of Vascular Surgery, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
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14
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van Manen L, Birkhoff WAJ, Eggermont J, Hoveling RJM, Nicklin P, Burggraaf J, Wilson R, Mieog JSD, Robinson DJ, Vahrmeijer AL, Bradbury MS, Dijkstra J. Detection of cutaneous oxygen saturation using a novel snapshot hyperspectral camera: a feasibility study. Quant Imaging Med Surg 2021; 11:3966-3977. [PMID: 34476182 DOI: 10.21037/qims-21-46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/15/2021] [Indexed: 11/06/2022]
Abstract
Background Tissue necrosis, a consequence of inadequate tissue oxygenation, is a common post-operative complication. As current surgical assessments are often limited to visual and tactile feedback, additional techniques that can aid in the interrogation of tissue viability are needed to improve patient outcomes. In this bi-institutional pilot study, the performance of a novel snapshot hyperspectral imaging camera to detect superficial cutaneous oxygen saturation (StO2) was evaluated. Methods Healthy human volunteers were recruited at two participating centers. Cutaneous StO2 of the forearm was determined by a snapshot hyperspectral camera on two separate study days during occlusion-reperfusion of the brachial artery and after induction of local vasodilation. To calculate the blood StO2 at each pixel in the multispectral image, spectra were selected, and fitting was performed over wavelengths ranging from 470 to 950 nm. Results Quantitative detection of physiological changes in cutaneous StO2 levels was feasible in all sixteen volunteers. A significant (P<0.001) decrease in cutaneous StO2 levels from 78.3% (SD: 15.3) at baseline to 60.6% (SD: 19.8) at the end of occlusion phase was observed, although StO2 levels returned to baseline after five minutes. Mean cutaneous StO2 values were similar in the same subjects on separate study days (Pearson R2: 0.92 and 0.77, respectively) at both centers. Local vasodilation did not yield significant changes in cutaneous StO2 values. Conclusions This pilot study demonstrated the feasibility of a snapshot hyperspectral camera for detecting quantitative physiological changes in cutaneous StO2 in normal human volunteers, and serves as a precursor for further validation in perioperative studies.
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Affiliation(s)
- Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jeroen Eggermont
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Leiden, The Netherlands
| | | | - Philip Nicklin
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Centre for Human Drug Research, Leiden, The Netherlands
| | - Roger Wilson
- Department of Anesthesiology, Critical Care Medicine, and Surgery, Memorial Sloan Kettering Cancer Center Research, New York, NY, USA
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Dominic J Robinson
- Erasmus Medical Center, Center for Optical Diagnostics and Therapy, Department of Otorhinolaryngology and Head and Neck Surgery, Rotterdam, The Netherlands
| | | | - Michelle S Bradbury
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,MSK-Cornell Center for Translation of Cancer Nanomedicines, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Molecular Pharmacology Program, Sloan Kettering Institute for Cancer Research, New York, NY, USA
| | - Jouke Dijkstra
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Leiden, The Netherlands
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15
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Sermsathanasawadi N, Pruekprasert K, Chruewkamlow N, Kittisares K, Warinpong T, Chinsakchai K, Wongwanit C, Ruangsetakit C, Mutirangura P. Peripheral blood mononuclear cell transplantation to treat no-option critical limb ischaemia: effectiveness and safety. J Wound Care 2021; 30:562-567. [PMID: 34256601 DOI: 10.12968/jowc.2021.30.7.562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. METHOD This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5-10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×1010) with CD34+ cells (2.1±1.2×108) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle-brachial index, toe-brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. RESULTS Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. CONCLUSION Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.
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Affiliation(s)
- Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanin Pruekprasert
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapol Chruewkamlow
- Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kulvara Kittisares
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanatphak Warinpong
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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16
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Interpretation of Near-Infrared Imaging in Acute and Chronic Wound Care. Diagnostics (Basel) 2021; 11:diagnostics11050778. [PMID: 33925990 PMCID: PMC8144992 DOI: 10.3390/diagnostics11050778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/22/2021] [Accepted: 04/23/2021] [Indexed: 11/16/2022] Open
Abstract
Vascular assessment is a critical component of wound care. Current routine noninvasive vascular studies have limitations which can give a false sense of security of the presence of adequate perfusion for healing. Near-infrared imaging modalities can serve as an additional diagnostic assessment of wounds in which adequate perfusion is a concern. Correct interpretation of near-infrared images obtained is critical as subtleties that exist in the acute and chronic wound population goes beyond the interpretation that increased signal is consistent with adequate perfusion for healing. The objective of this paper is to educate providers on the correct interpretation of this point-of-care imaging modality in day-to-day wound-care practice to guide clinical decision-making for rapid wound resolution.
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17
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Catella J, Long A, Mazzolai L. What Is Currently the Role of TcPO2 in the Choice of the Amputation Level of Lower Limbs? A Comprehensive Review. J Clin Med 2021; 10:jcm10071413. [PMID: 33915838 PMCID: PMC8037184 DOI: 10.3390/jcm10071413] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 11/18/2022] Open
Abstract
Some patients still require major amputation for lower extremity peripheral arterial disease treatment. The purpose of pre-operative amputation level selection is to determine the most distal amputation site with the highest healing probability without re-amputation. Transcutaneous oximetry (TcPO2) can detect viable tissue with the highest probability of healing. Several factors affect the accuracy of TcPO2; nevertheless, surgeons rely on TcPO2 values to determine the optimal amputation level. Background about the development of TcPO2, methods of measurement, consequences of lower limb amputation level, and the place of TcPO2 in the choice of the amputation level are reviewed herein. Most of the retrospective studies indicated that calf TcPO2 values greater than 40 mmHg were associated with a high percentage of successful wound healing after below-knee-amputation, whereas values lower than 20 mmHg indicated an increased risk of unsuccessful healing. However, a consensus on the precise cut-off value of TcPO2 necessary to assure healing is missing. Ways of improvement for TcPO2 performance applied to the optimization of the amputation-level are reported herein. Further prospective data are needed to better approach a TcPO2 value that will promise an acceptable risk of re-amputation. Standardized TcPO2 measurement is crucial to ensure quality of data.
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Affiliation(s)
- Judith Catella
- Service de Médecine Interne et Vasculaire, Hopital Edouard Herriot, Hospices Civils de Lyon, 69003 Lyon, France;
- Laboratoire d’Excellence du Globule Rouge (Labex GR-Ex), Sorbonne, 75015 Paris, France
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Université Claude Bernard Lyon 1, Université de Lyon, 69008 Lyon, France
- UMR 5305: Laboratoire de Biologie Tissulaire et Ingénierie Thérapeutique, CNRS/Université Claude Bernard Lyon 1, Institut de Biologie et Chimie des Protéines, 7 Passage du Vercors, 69367 Lyon, France
- Correspondence: ; Tel.: +33-472117791; Fax: +33-472116949
| | - Anne Long
- Service de Médecine Interne et Vasculaire, Hopital Edouard Herriot, Hospices Civils de Lyon, 69003 Lyon, France;
- Laboratoire Interuniversitaire de Biologie de la Motricité (LIBM) EA7424, Université Claude Bernard Lyon 1, Université de Lyon, 69008 Lyon, France
| | - Lucia Mazzolai
- Service d’Angiologie, Département Coeur et Vaisseaux, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland;
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18
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Sinusoidal changes in transcutaneous oxygen pressure, suggesting Cheyne-Stokes respiration, are frequent and of poor prognosis among patients with suspected critical limb ischemia. Atherosclerosis 2020; 316:15-24. [PMID: 33260007 DOI: 10.1016/j.atherosclerosis.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Transcutaneous oxygen pressure (TcpO2) is used in patients with suspected critical limb ischemia (CLI). Sinusoidal changes (SC~) in TcpO2 are found in patients with Cheyne-Stokes respiration (CSR). We aimed to determine the characteristics of TcpO2 changes at rest in patients with suspected CLI, define the objective criteria for SC ~ TcpO2 patterns (SC+), and estimate the prevalence of SC+ in our population and its impact on the outcome. METHODS We retrospectively analyzed 300 chest TcpO2 recordings performed in a 16-month period. We determined the presence/absence of SC ~ TcpO2 by visual analysis. We determined the acceptable error in the regularity of peaks of the cross-correlation with ROC curve analysis, among patients with typical SC ~ TcpO2 and non-sinusoidal patterns. Then, we defined SC + as a minimum of five peaks, a standard deviation of TcpO2 >1.25 mmHg, an error in regularity of peaks of the cross-correlation < 10%, and a cycle length between 30 and 100 s. In patients included until October 2019, we compared the outcome as a function of SC + or SC- with Cox models. RESULTS Mathematical detection of SC + found that 43 patients (14.3%) fulfilled all four defined criteria at the chest level, but only 23 did so at the limb level. In the follow-up of 207 patients, the presence of Sc ~ TcpO2 at the chest significantly increased the risk of mortality: hazard ratio: 2.69 [95%CI: 1.37-5.30]; p < 0.005. CONCLUSIONS SC ~ TcpO2 is frequent, and is associated with a poor outcome in patients with suspected CLI.
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Abbade LPF, Frade MAC, Pegas JRP, Dadalti-Granja P, Garcia LC, Bueno Filho R, Parenti CEF. Consensus on the diagnosis and management of chronic leg ulcers - Brazilian Society of Dermatology. An Bras Dermatol 2020; 95 Suppl 1:1-18. [PMID: 33371937 PMCID: PMC7772605 DOI: 10.1016/j.abd.2020.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/03/2020] [Accepted: 06/07/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Chronic leg ulcers affect a large portion of the adult population and cause a significant social and economic impact, related to outpatient and hospital care, absence from work, social security expenses, and reduced quality of life. The correct diagnosis and therapeutic approach are essential for a favorable evolution. OBJECTIVE To gather the experience of Brazilian dermatologists, reviewing the specialized literature to prepare recommendations for the diagnosis and treatment of the main types of chronic leg ulcers. METHODS Seven specialists from six university centers with experience in chronic leg ulcers were appointed by the Brazilian Society of Dermatology to reach a consensus on the diagnosis and therapeutic management of these ulcers. Based on the adapted DELPHI methodology, relevant elements were considered in the diagnosis and treatment of chronic leg ulcers of the most common causes; then, the recent literature was analyzed using the best scientific evidence. RESULTS The following themes were defined as relevant for this consensus - the most prevalent differential etiological diagnoses of chronic leg ulcers (venous, arterial, neuropathic, and hypertensive ulcers), as well as the management of each one. It also included the topic of general principles for local management, common to chronic ulcers, regardless of the etiology. CONCLUSION This consensus addressed the main etiologies of chronic leg ulcers and their management based on scientific evidence to assist dermatologists and other health professionals and benefit the greatest number of patients with this condition.
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Affiliation(s)
- Luciana Patricia Fernandes Abbade
- Department of Infectious Diseases, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil.
| | - Marco Andrey Cipriani Frade
- Department of Internal Medicine (Dermatology Division), Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - José Roberto Pereira Pegas
- Dermatology Service, Hospital Padre Bento de Guarulhos, Guarulhos, SP, Brazil; Discipline of Dermatology, Faculty of Medicine, Universidade da Cidade de São Paulo, São Paulo, SP, Brazil; Discipline of Dermatology, Faculty of Medicine, Jundiaí, SP, Brazil
| | - Paula Dadalti-Granja
- Department of Clinical Medicine (Discipline of Dermatology), Universidade Federal Fluminense, Niterói, RJ, Brazil
| | - Lucas Campos Garcia
- Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Roberto Bueno Filho
- Dermatology Service, Hospital das Clínicas, Faculty of Medicine, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
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20
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Berli MC, Jundt-Ecker M, Meier MR, Hofer M, Schöni M, Götschi T, Uçkay I, Böni T, Waibel FWA. Resting TcPO2 levels decrease during liner wear in persons with a transtibial amputation. PLoS One 2020; 15:e0239930. [PMID: 32986780 PMCID: PMC7521692 DOI: 10.1371/journal.pone.0239930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 09/16/2020] [Indexed: 11/30/2022] Open
Abstract
Background In our clinic, a substantial number of patients present with transtibial residual limb pain of no specific somatic origin. Silicone liner induced tissue compression may reduce blood flow, possibly causing residual limb pain. Thus, as a first step we investigated if the liner itself has an effect on transcutaneous oxygen pressure (TcPO2). Methods Persons with unilateral transtibial amputation and residual limb pain of unknown origin were included. Medical history, including residual limb pain, was recorded, and the SF-36 administered. Resting TcPO2 levels were measured in the supine position and without a liner at 0, 10, 20 and 30 minutes using two sensors: one placed in the Transverse plane over the tip of the Tibia End (= TTE), the other placed in the Sagittal plane, distally over the Peroneal Compartment (= SPC). Measurements were repeated with specially prepared liners avoiding additional pressure due to sensor placement. Statistical analyses were performed using SPSS. Results Twenty persons (9 women, 11 men) with a mean age of 68.65 years (range 47–86 years) participated. The transtibial amputation occurred on average 43 months prior to study entry (range 3–119 months). With liner wear, both sensors measured TcPO2 levels that were significantly lower than those measured without a liner (TTE: p < 0.001; SPC: p = 0.002) after 10, 20 and 30 minutes. No significant differences were found between TcPO2 levels over time between the sensors. There were no significant associations between TcPO2 levels and pain, smoking status, age, duration of daily liner use, mobility level, and revision history. Conclusion Resting TcPO2 levels decreased significantly while wearing a liner alone, without a prosthetic socket. Further studies are required to investigate the effect of liner wear on exercise TcPO2 levels.
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Affiliation(s)
- Martin C. Berli
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Michèle Jundt-Ecker
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | | | | | - Madlaina Schöni
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopaedic Surgery, Institute for Biomechanics, University of Zurich, ETH Zurich, Balgrist Campus, Zurich, Switzerland
| | - Ilker Uçkay
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Thomas Böni
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
| | - Felix W. A. Waibel
- Department of Orthopaedic Surgery, Balgrist University Hospital, Zurich, Switzerland
- * E-mail:
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Abstract
Peripheral arterial disease (PAD) affects many individuals worldwide and is associated with increased morbidity and mortality. Controversy exists on whether or not to screen asymptomatic patients. Further complicating this is that many patients with a chronic lower extremity wound are often asymptomatic. PAD and traditional noninvasive vascular studies may be inaccurate in providing a correct diagnosis. A review of current and novel vascular assessment modalities along with their benefits and limitations are presented here. A combination of these vascular assessments may help improve accuracy in diagnosis, providing timely care to those patients in need.
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Affiliation(s)
- Jonathan F Arnold
- Mercy Healing Center, 701 10th Street Southeast, Cedar Rapids, IA 52403, USA.
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22
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Rogers RK, Montero-Baker M, Biswas M, Morrison J, Braun J. Assessment of foot perfusion: Overview of modalities, review of evidence, and identification of evidence gaps. Vasc Med 2020; 25:235-245. [PMID: 32362209 DOI: 10.1177/1358863x20909433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Patients with critical limb ischemia have nonhealing wounds and/or ischemic rest pain and are at high risk for amputation and mortality. Accurate evaluation of foot perfusion should help avoid unnecessary amputation, guide revascularization strategies, and offer efficient surveillance for patency. Our aim is to review current modalities of assessing foot perfusion in the context of the practical clinical management of patients with critical limb ischemia.
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Affiliation(s)
- R Kevin Rogers
- Section of Vascular Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Minakshi Biswas
- Section of Vascular Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Justin Morrison
- Section of Vascular Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Jonathan Braun
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
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Risk factors for reamputations in patients amputated after revascularization for critical limb-threatening ischemia. J Vasc Surg 2020; 73:258-266.e1. [PMID: 32360684 DOI: 10.1016/j.jvs.2020.03.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 03/18/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Despite vascular intervention, patients with critical limb-threatening ischemia (CLTI) have a high risk of amputation. Furthermore, this group has a high risk for stump complications and reamputation. The primary aim of this study was to identify risk factors predicting reamputation after a major lower limb amputation in patients revascularized because of CLTI. The secondary aim was to investigate mortality after major lower limb amputation. METHODS There were 288 patients who underwent a major ipsilateral amputation after revascularization because of CLTI in Stockholm, Sweden, during 2007 to 2013. The main outcome was ipsilateral reamputation. RESULTS Of 288 patients, 50 patients had a reamputation and 222 died during the 11-year follow-up. Patients with ischemic pain as an indication for primary amputation had nearly four times higher risk for a reamputation compared with those with a nonhealing ulcer (subdistribution hazard ratio, 3.55; confidence interval, 1.55-8.17). Higher age was associated with an increased risk for death in the multivariable analysis (hazard ratio, 1.03; confidence interval, 1.02-1.04). CONCLUSIONS Patients with ischemic pain as an indication for amputation have an elevated risk of reamputation. Ischemic pain may be indicative of a more extensive and proximal ischemia compared with patients with foot tissue loss. An extended evaluation of the preoperative circulation before amputation may facilitate the choice of amputation level and could lead to a reduction of reamputations.
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Janssen ERI, van Silfhout L. Duplex Ultrasound May Predict the Best Level of Lower Limb Amputation in Patients with Chronic Limb-Threatening Ischemia: A Retrospective Observational Cohort Study. Ann Vasc Surg 2020; 67:403-410. [PMID: 32205236 DOI: 10.1016/j.avsg.2020.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Despite improved revascularization options, many patients with chronic limb-threatening ischemia (CLI) require lower limb amputation. Duplex ultrasound (DUS) is recommended as first-choice imaging technique in CLI. However, the prognostic utility of DUS for planning lower limb amputations has never been described before. This study aims to evaluate if DUS and findings from physical examination could be used to help predict the best level of lower limb amputation in patients with CLI. METHODS A retrospective cohort of 124 patients with CLI and a lower limb amputation was analyzed. Outcome measurements were reoperation, revision, and conversion rates, which were related to findings from physical examination and DUS examinations. RESULTS Thirty-nine reoperations were performed, of which 17 stump revisions and 22 conversions were from below- to above-knee amputation. There was a discrepancy in findings of physical examination and DUS of 25% and 64% of femoral and popliteal pulsations respectively. Conversion rates increased with a more proximal occlusion on DUS. All patients with a vascular occlusion in the aortoiliac trajectory or deep femoral artery required a higher amputation level. CONCLUSIONS Physical examination seems to be unreliable, and therefore should not be used to assess the optimal level of lower extremity amputation. Performing a primary above-knee amputation in patients with vascular occlusion in the aortoiliac trajectory or deep femoral artery could significantly reduce reoperation rates.
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Affiliation(s)
- Emmy R I Janssen
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lysanne van Silfhout
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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25
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Bramley JL, Worsley PR, Bostan LE, Bader DL, Dickinson AS. Establishing a measurement array to assess tissue tolerance during loading representative of prosthetic use. Med Eng Phys 2020; 78:39-47. [PMID: 32035813 DOI: 10.1016/j.medengphy.2020.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In the early stages of rehabilitation after primary amputation, residual limb soft tissues have not been mechanically conditioned to support load and are vulnerable to damage from prosthetic use. There is limited quantitative knowledge of skin and soft tissue response to prosthetic loading. METHODS An in-vivo protocol was developed to establish suitable measures to assess tissue tolerance during loading representative of early prosthesis use. Ten participants without amputation one participant with trans-tibial amputation were recruited, and pressure applied to their calf in increments from 20 to 60 mmHg. Measurements were recorded at relevant skin sites including interface pressures, transcutaneous oxygen (TCPO2) and carbon dioxide (TCPCO2) tensions and inflammatory biomarkers. FINDINGS At the maximum cuff pressure, mean interface pressures were between 66 and 74 mmHg, associated with decreased TCPO2 values. On the release of pressure, the ischaemic response was reversed. Significant upregulation (p < 0.05) in inflammatory biomarker IL-1α and its antagonist IL-1RA were observed at all sites immediately following loading. INTERPRETATION The protocol was successful in applying representative prosthetic loads to lower limb tissues and monitoring the physiological response, both in terms of tissue ischemia and skin inflammation. Results indicated that the measurement approaches were sensitive to changes in interface conditions, offering a promising approach to monitor tissue status for people with amputation.
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Affiliation(s)
- J L Bramley
- Bioengineering Science Research Group, Faculty of Engineering and Physical Sciences, University of Southampton, Highfield Campus, University Rd, Southampton SO17 1BJ, UK
| | - P R Worsley
- Skin Health Research Group, Faculty of Environmental and Life Sciences, University of Southampton, UK
| | - L E Bostan
- Skin Health Research Group, Faculty of Environmental and Life Sciences, University of Southampton, UK
| | - D L Bader
- Skin Health Research Group, Faculty of Environmental and Life Sciences, University of Southampton, UK
| | - A S Dickinson
- Bioengineering Science Research Group, Faculty of Engineering and Physical Sciences, University of Southampton, Highfield Campus, University Rd, Southampton SO17 1BJ, UK.
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26
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van den Hoven P, Ooms S, van Manen L, van der Bogt KEA, van Schaik J, Hamming JF, Vahrmeijer AL, van der Vorst JR, Mieog JSD. A systematic review of the use of near-infrared fluorescence imaging in patients with peripheral artery disease. J Vasc Surg 2020; 70:286-297.e1. [PMID: 31230648 DOI: 10.1016/j.jvs.2018.11.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/19/2018] [Indexed: 01/18/2023]
Abstract
OBJECTIVE In the diagnosis of peripheral artery disease (PAD), the ankle-brachial index plays an important role. However, results of the ankle-brachial index are unreliable in patients with severe media sclerosis. Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) can provide information about tissue perfusion and has already been studied in oncologic, reconstructive, and cardiac surgery. For patients with PAD, this technique might give insight into skin perfusion and thereby guide treatment. We performed a systematic review of the literature on the use of NIR fluorescence imaging in patients with PAD. METHODS PubMed, MEDLINE, Embase, and Cochrane were searched for articles and abstracts on the application of NIR fluorescence imaging using ICG as fluorescent dye in patients with PAD. Our search strategy combined the terms "fluorescence," "ICG," or synonyms and "peripheral artery disease" or synonyms. The extracted data included fluorescence parameters and test characteristics for diagnosis of PAD. RESULTS Twenty-three articles were found eligible for this review using 18 different parameters for evaluation of the fluorescence signal intensity. NIR fluorescence imaging was used for four main indications: diagnosis, quality control in revascularization, guidance in amputation surgery, and visualization of vascular structures. For the diagnosis of PAD, NIR fluorescence imaging yields a sensitivity ranging from 67% to 100% and a specificity varying between 72% and 100%. Significant increases in multiple fluorescence parameters were found in comparing patients before and after revascularization. CONCLUSIONS NIR fluorescence imaging can be used for several indications in patients with PAD. NIR fluorescence imaging seems promising in diagnosis of PAD and guidance of surgeons in treatment, especially in patients in whom current diagnostic methods are not applicable. Further standardization is needed to reliably use this modality in patients with PAD.
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Affiliation(s)
- Pim van den Hoven
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Ooms
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Labrinus van Manen
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jan van Schaik
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Jaap F Hamming
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
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Effect of temperature-control liner materials on long-term outcomes of lower limb prosthesis use: a randomized controlled trial protocol. Trials 2020; 21:61. [PMID: 31924257 PMCID: PMC6954540 DOI: 10.1186/s13063-019-3920-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/19/2019] [Indexed: 11/30/2022] Open
Abstract
Background In people living with limb loss, addressing the resulting functional deficit with prostheses increases the risk for secondary conditions such as pressure sores, impaired blood perfusion, and injuries from accidental falls. Any of those occurrences can render the prosthesis temporarily useless, making it challenging for users to engage in many activities of daily life, including work, exercise, and social participation. Many of the described issues originate at the interface between residual limb and prosthetic socket, where the objectives of sufficient weight distribution and suspension are conflicting with the necessity to facilitate heat exchange and limit contact pressure and friction. Recently, prosthesis liners that contain phase-change material have become commercially available, holding the promise that the micro climate at the interface between the residual limb skin and the prosthetic socket can be regulated to reduce the users’ tendency to sweat. Preliminary studies on these liners indicate that the socket temperatures inside the socket stayed lower and rose slower than in conventional liners. However, the clinical relevance of those findings remains unclear. The purpose of this study is to investigate whether longer (6+ months) periods of use of phase-change material based temperature-control liners have clinically meaningful effects. Methods The protocol is a double-blind longitudinal cross-over research design. A sample of trans-tibial prosthesis users are wearing their regular gel or silicone liners for six months and phase-change material liners for another six months in a randomized sequence. Their prostheses is equipped with activity monitors to detect days when they could not wear their prosthesis. In six-week intervals, individuals’ activity, physical performance, and overall prosthesis assessment is recorded using standardized methods. Discussion Expected results will inform prescription and reimbursement practice of phase-change material-based prosthesis liners and will help improve and economize prosthetic fitting for people with limb loss. The design and duration of the protocol, including randomization, blinding, and within-subject comparison, will generate scientific evidence of a comparably high level. Inclusion of a comparably large sample and different climates, e.g. across all four seasons, will make findings applicable to a large number of prosthesis users. Trial registration Clinicaltrials.gov, NCT03428815. Registered on 12 February 2018.
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 707] [Impact Index Per Article: 141.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Kanick SC, Schneider PA, Klitzman B, Wisniewski NA, Rebrin K. Continuous monitoring of interstitial tissue oxygen using subcutaneous oxygen microsensors: In vivo characterization in healthy volunteers. Microvasc Res 2019; 124:6-18. [PMID: 30742844 PMCID: PMC6570499 DOI: 10.1016/j.mvr.2019.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/04/2019] [Accepted: 02/05/2019] [Indexed: 11/19/2022]
Abstract
Measurements of regional tissue oxygen serve as a proxy to monitor local perfusion and have the potential to guide therapeutic decisions in multiple clinical disciplines. Transcutaneous oximetry (tcpO2) is a commercially available noninvasive technique that uses an electrode to warm underlying skin tissue and measure the resulting oxygen tension at the skin surface. A novel approach is to directly measure interstitial tissue oxygen using subcutaneous oxygen microsensors composed of a biocompatible hydrogel carrier platform with embedded oxygen sensing molecules. After initial injection of the hydrogel into subcutaneous tissue, noninvasive optical measurements of phosphorescence-based emissions at the skin surface are used to sense oxygen in the subcutaneous interstitial space. The object of the present study was to characterize the in vivo performance of subcutaneous microsensors and compare with transcutaneous oximetry (tcpO2). Vascular occlusion tests were performed on the arms of 7 healthy volunteers, with repeated tests occurring 1 to 10 weeks after sensor injection, yielding 95 total tests for analysis. Comparative analysis characterized the response of both devices to decreases in tissue oxygen during occlusion and to increases in tissue oxygen following release of the occlusion. Results indicated: (I) time traces returned by microsensors and tcpO2 were highly correlated, with the median (interquartile range) correlation coefficient of r = 0.93 (0.10); (II) both microsensors and tcpO2 sensed a statistically significant decrease in normalized oxygen during occlusion (p < 0.001 for each device); (III) microsensors detected faster rates change (p < 0.001) and detected overshoot during recovery more frequently (38% vs. 4% of tests); (IV) inter-measurement analysis showed no correlation of baseline values between microsensors and tcpO2 (r = 0.03), but comparison of integrated oxygen dynamics showed similar variation in the normalized response to occlusion between devices (p = 0.06), (V) intra-measurement analysis revealed that microsensors detect greater physiological fluctuations than tcpO2 (p < 0.001) and may provide enhanced sensitivity to processes such as vasomotion. Additionally, the functional response of microsensors was not significantly different across time groupings (per month) post-injection (p = 0.61). Although the compared devices have differences in the mechanisms used to sense oxygen, these findings demonstrate that subcutaneous oxygen microsensors measure changes in interstitial tissue oxygen in human subjects in vivo.
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Affiliation(s)
| | | | - Bruce Klitzman
- Kenan Plastic Surgery Research Labs and Biomedical Engineering, Duke University, Durham, NC, USA
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30
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 686] [Impact Index Per Article: 137.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Pierre-Louis WS, Bath J, Mikkilineni S, Scott MC, Harlander-Locke M, Rasor Z, Smeds M. Neutrophil to Lymphocyte Ratio as a Predictor of Outcomes after Amputation. Ann Vasc Surg 2018; 54:84-91. [PMID: 30339899 DOI: 10.1016/j.avsg.2018.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The neutrophil-to-lymphocyte ratio (NLR) has become a prognostic marker for proinflammatory states. It is associated with outcomes in many clinical processes including critical limb ischemia. We sought to identify predictors of amputation failure and mortality, in addition to the role of NLR in patients undergoing above-knee amputations (AKAs) or below-knee amputations (BKAs). METHODS All patients undergoing BKA or AKA between 2004 and 2014 at 3 institutions were identified and analyzed (n = 513). Patients were excluded if they did not have a complete blood count with differential within 7 days prior to their operations. Comparison groups were formed between patients requiring unplanned revision and those who did not, and additionally between survivors and nonsurvivors at 30 days postamputation. Patient demographics, intraoperative data, and postoperative courses were compared. A multinomial logistic regression model was created to further compare the groups. RESULTS Four hundred and ten patients were included for analysis, of which 142 (35%) required unplanned revision. Nearly 5% of patients (19/410) died within 30 days of the initial amputation. On univariate analysis, those requiring revision were more likely to be current smokers compared to former smokers (P = 0.004 and P = 0.021, respectively), have a lower ankle-brachial index (ABI) (P = 0.019), and have undergone a BKA (P < 0.001). Patients with congestive heart failure (CHF) were less likely to require a revision after an amputation (P = 0.007). Postoperative NLR was higher in patients requiring revision (9.9 vs. 7.0, P < 0.001) and both preoperative and postoperative NLRs were higher in those with 30-day mortality (21.0 vs. 7.0, P < 0.001; 19.4 vs. 7.5, P < 0.001). A multinomial logistic regression model identified CHF (P = 0.004), ABI (P = 0.041), and elevated body mass index (BMI, P = 0.045) as predictors of revision, while coronary artery disease (CAD, P = 0.031), CHF (P = 0.029), and postoperative NLR (P < 0.001) were predictive of 30-day mortality. CONCLUSIONS Postoperative elevated NLR, CAD, and CHF are predictors of 30-day mortality in patients undergoing major limb amputation, while CHF, elevated ABI, and high BMI are predictors of revision. This study suggests that NLR may have a role as a biomarker for poor outcomes in patients with underlying peripheral vascular disease and warrants further investigation.
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Affiliation(s)
| | - Jonathan Bath
- Division of Vascular Surgery, University of Missouri Hospitals & Clinics, Columbia, MO
| | | | - Michael C Scott
- University of Arkansas for Medical Sciences, Little Rock, AR
| | | | - Zachary Rasor
- Division of Podiatric Surgery, University of Cincinnati Medical Center, Cincinnati, OH
| | - Matthew Smeds
- Division of Vascular Surgery, St. Louis University, St. Louis, MO
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Response to Letter from Abraham and colleagues, regarding “Monitoring the biomechanical and physiological effects of postural changes during leisure chair sitting”. J Tissue Viability 2018; 27:189. [DOI: 10.1016/j.jtv.2018.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 05/28/2018] [Indexed: 11/18/2022]
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De Silva GS, Saffaf K, Sanchez LA, Zayed MA. Amputation stump perfusion is predictive of post-operative necrotic eschar formation. Am J Surg 2018; 216:540-546. [PMID: 29789123 PMCID: PMC6129216 DOI: 10.1016/j.amjsurg.2018.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/22/2018] [Accepted: 05/06/2018] [Indexed: 12/26/2022]
Abstract
Background A large proportion of patients develop poor amputation stump healing. We hypothesize that Laser-Assisted Fluorescent Angiography (LAFA) can predict inadequate tissue perfusion and healing. Methods Over an 8-month period we reviewed all patients who underwent lower extremity amputation and LAFA. We evaluated intra-operative LAFA global and segmental stump perfusion, and post-operative modified Bates-Jensen (mBJS) wound healing scores. Results In 15 patients, amputation stumps with lower global perfusion demonstrated higher mBJS (P = 0.01). Lower suture-line perfusion also correlated with more eschar formation (P < 0.001). Diabetic patients had higher mBJS (P = 0.009), lower stump perfusion (P = 0.02), and increased eschar volume (P < 0.001). Conclusion LAFA is a useful adjunct for intra-operative stump perfusion assessment and can predict areas of poor stump healing and eschar formation. Diabetic patients seem to be at higher risk of stump eschar formation.
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Affiliation(s)
- Gayan S De Silva
- Washington University School of Medicine, Department of Surgery, Section of Vascular Surgery, St. Louis, MO, USA
| | - Khalid Saffaf
- Washington University School of Medicine, Department of Surgery, Section of Vascular Surgery, St. Louis, MO, USA
| | - Luis A Sanchez
- Washington University School of Medicine, Department of Surgery, Section of Vascular Surgery, St. Louis, MO, USA
| | - Mohamed A Zayed
- Washington University School of Medicine, Department of Surgery, Section of Vascular Surgery, St. Louis, MO, USA; Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA.
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Patel HM, Bulsara SS, Banerjee S, Sahu T, Sheorain VK, Grover T, Parakh R. Indocyanine Green Angiography to Prognosticate Healing of Foot Ulcer in Critical Limb Ischemia: A Novel Technique. Ann Vasc Surg 2018; 51:86-94. [PMID: 29679687 DOI: 10.1016/j.avsg.2018.02.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/23/2018] [Accepted: 02/05/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND To predict wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Current methods such as ankle-brachial index (ABI), color Doppler and transcutaneous oxygen pressure (TCPO2), and computed tomography angiography are lacking in demonstrating regional perfusion. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. This study was conducted to demonstrate successes of revascularization procedure in CLI patients based on ICGA data. METHODS A total of 47 patients with grade 2 or grade 3 University of Texas Wound Classification System ischemic foot ulcer undergoing lower limb revascularization procedure were included in this study, from July 2014 to May 2016. ICGA with intravenous 0.1 mg/kg of 0.1% indocyanine green dye was performed before and after revascularization procedure. ICGA data maximum unit, blush time, and blush rate were compared between prerevascularization and postrevascularization data, along with ABI and TCPO2. RESULTS Out of 47 patients (45 males and 2 females), 43 underwent endovascular revascularization and 4 underwent open procedure. Of all, 76.6% of patients were diabetic and 46.8% were hypertensive. Also, 31.9% had coronary artery disease, 21.2% had history of cerebrovascular disease, 23% had chronic kidney disease, and 74.4% were chronic smokers. A total of 37 patients' ulcer healed completely on follow-up with significant improvement (P < 0.05) in preoperative and postoperative ABI, TCPO2, and ICGA data. Ten patients' ulcer did not heal in the follow-up period. In those 10 patients, preoperative and postoperative ABI and TCPO2 improved, but ICGA data were not improved postoperatively (P > 0.05). CONCLUSIONS ICGA is an evolving tool to quantify regional perfusion in CLI. ICGA parameters provide qualitative real-time visual images of perfusion in area of interest as well as quantitative information of perfusion.
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Affiliation(s)
- Hiten M Patel
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India.
| | - Shahzad S Bulsara
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
| | - Shubhabrata Banerjee
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
| | - Tapish Sahu
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
| | - Virender K Sheorain
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
| | - Tarun Grover
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
| | - Rajiv Parakh
- Division of Vascular and Endovascular Sciences, Medanta-The Medicity Hospital, Gurgaon, Haryana, India
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Highsmith MJ, Kahle JT, Miro RM, Orendurff MS, Lewandowski AL, Orriola JJ, Sutton B, Ertl JP. Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews. ACTA ACUST UNITED AC 2018; 53:157-84. [PMID: 27149143 DOI: 10.1682/jrrd.2015.03.0046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 07/14/2015] [Indexed: 11/05/2022]
Abstract
Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.
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Affiliation(s)
- M Jason Highsmith
- Department of Veterans Affairs and Department of Defense Extremity Trauma and Amputation Center of Excellence, Washington, DC
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Dremin VV, Zherebtsov EA, Sidorov VV, Krupatkin AI, Makovik IN, Zherebtsova AI, Zharkikh EV, Potapova EV, Dunaev AV, Doronin AA, Bykov AV, Rafailov IE, Litvinova KS, Sokolovski SG, Rafailov EU. Multimodal optical measurement for study of lower limb tissue viability in patients with diabetes mellitus. JOURNAL OF BIOMEDICAL OPTICS 2017; 22:1-10. [PMID: 28825287 DOI: 10.1117/1.jbo.22.8.085003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 07/21/2017] [Indexed: 05/22/2023]
Abstract
According to the International Diabetes Federation, the challenge of early stage diagnosis and treatment effectiveness monitoring in diabetes is currently one of the highest priorities in modern healthcare. The potential of combined measurements of skin fluorescence and blood perfusion by the laser Doppler flowmetry method in diagnostics of low limb diabetes complications was evaluated. Using Monte Carlo probabilistic modeling, the diagnostic volume and depth of the diagnosis were evaluated. The experimental study involved 76 patients with type 2 diabetes mellitus. These patients were divided into two groups depending on the degree of complications. The control group consisted of 48 healthy volunteers. The local thermal stimulation was selected as a stimulus on the blood microcirculation system. The experimental studies have shown that diabetic patients have elevated values of normalized fluorescence amplitudes, as well as a lower perfusion response to local heating. In the group of people with diabetes with trophic ulcers, these parameters also significantly differ from the control and diabetes only groups. Thus, the intensity of skin fluorescence and level of tissue blood perfusion can act as markers for various degrees of complications from the beginning of diabetes to the formation of trophic ulcers.
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Affiliation(s)
- Viktor V Dremin
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Evgeny A Zherebtsov
- Aston University, Aston Institute of Photonic Technologies, Optoelectronics and Biomedical Photonics, United Kingdom
| | | | | | - Irina N Makovik
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Angelina I Zherebtsova
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Elena V Zharkikh
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Elena V Potapova
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Andrey V Dunaev
- Orel State University named after I.S. Turgenev, Biomedical Photonics Laboratory of University Clini, Russia
| | - Alexander A Doronin
- Yale University, Department of Computer Science, Computer Graphics Group, New Haven, Connecticut, United States
| | - Alexander V Bykov
- University of Oulu, Optoelectronics and Measurement Techniques Laboratory, Faculty of Information Te, Finland
| | - Ilya E Rafailov
- Aston University, School of Engineering and Applied Sciences, Aston Institute of Photonic Technologi, United Kingdom
| | | | - Sergei G Sokolovski
- Aston University, Aston Institute of Photonic Technologies, Optoelectronics and Biomedical Photonics, United Kingdom
| | - Edik U Rafailov
- Aston University, Aston Institute of Photonic Technologies, Optoelectronics and Biomedical Photonics, United Kingdom
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Li WW, Carter MJ, Mashiach E, Guthrie SD. Vascular assessment of wound healing: a clinical review. Int Wound J 2017; 14:460-469. [PMID: 27374428 PMCID: PMC7950183 DOI: 10.1111/iwj.12622] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/28/2016] [Indexed: 12/17/2022] Open
Abstract
Although macrovascular screening of patients with chronic wounds, particularly in the lower extremities, is accepted as part of clinical practice guidelines, microvascular investigation is less commonly used for a variety of reasons. This can be an issue because most patients with macrovascular disease also develop concomitant microvascular dysfunction. Part of the reason for less comprehensive microvascular screening has been the lack of suitable imaging techniques that can quantify microvascular dysfunction in connection with non-healing chronic wounds. This is changing with the introduction of fluorescence microangiography. The objective of this review is to examine macro- and microvascular disease, the strengths and limitations of the approaches used and to highlight the importance of microvascular angiography in the context of wound healing.
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Katsui S, Inoue Y, Igari K, Toyofuku T, Kudo T, Uetake H. Novel assessment tool based on laser speckle contrast imaging to diagnose severe ischemia in the lower limb for patients with peripheral arterial disease. Lasers Surg Med 2017; 49:645-651. [PMID: 28370223 PMCID: PMC5573943 DOI: 10.1002/lsm.22669] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 12/31/2022]
Abstract
Objective We propose a new assessment tool to diagnose severe ischemia of the lower limb in peripheral arterial disease, using laser speckle contrast imaging to evaluate heating‐induced microcirculatory fluctuations in the proximal and distal sites of the dorsal foot. Study Design A cross‐sectional study. Methods We recorded the slope describing the behavior of perfusion values (decrease or plateau) following the initial, heating‐induced increase in perfusion in 63 feet of patients with clinical signs of peripheral arterial disease. Results The plateau and decrease groups were defined as having perfusion slopes of <0.20 and ≥0.20 PU/min, respectively. Transcutaneous oxygen tension was significantly lower (P < 0.001) in the plateau than in the decrease group (8 vs. 45 mmHg), indicating more severe ischemia. The laser speckle contrast imaging thermal load test discriminated transcutaneous oxygen tension <30 mmHg with good sensitivity (78.7%) and specificity (96.2%), and an area under the curve of 0.908. Conclusions Both transcutaneous oxygen tension and the laser speckle contrast imaging thermal load test are useful in diagnosing severe ischemia in the foot. Lasers Surg. Med. 49:645–651, 2017. © 2017. The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Sotaro Katsui
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshinori Inoue
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kimihiro Igari
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takahiro Toyofuku
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshifumi Kudo
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroyuki Uetake
- Department of Surgical Specialties, Tokyo Medical and Dental University, Tokyo, Japan
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Aoyama N, Nishinari M, Ohtani S, Kanai A, Noda C, Hirata M, Miyamoto A, Watanabe M, Minamino T, Izumi T, Ako J. Clinical features and predictors of patients with critical limb ischemia who responded to autologous mononuclear cell transplantation for therapeutic angiogenesis. Heart Vessels 2017; 32:1099-1108. [DOI: 10.1007/s00380-017-0968-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 03/10/2017] [Indexed: 01/11/2023]
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Reiner MM, Khoury WE, Canales MB, Chmielewski RA, Patel K, Razzante MC, Cloughtery CO, Rowland DY. Procalcitonin as a Biomarker for Predicting Amputation Level in Lower Extremity Infections. J Foot Ankle Surg 2017; 56:484-491. [PMID: 28341493 DOI: 10.1053/j.jfas.2017.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Indexed: 02/03/2023]
Abstract
Inflammatory markers are essential tools in the decision-making process for lower extremity infections. When coupled with objective findings, clinicians can more accurately diagnose and treat these entities. Typically, markers such as the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are used to initially assess these patients or monitor the progression of medical or surgical therapy. Procalcitonin is a newer inflammatory marker that is specific for an infectious process. Originally, procalcitonin was used to monitor antibiotic therapy and sepsis for patients in the intensive care setting, but it has now been expanded to other facets of medicine. The utility of procalcitonin has been described for diagnosing infection or osteomyelitis in diabetic foot ulcers. However, limited research has compared inflammatory marker levels and the level of amputation. A retrospective inpatient medical record review was performed of 156 consecutive patient occurrences during 25 months in which surgical intervention was required for a lower extremity infection and an initial procalcitonin level had been obtained. This initial procalcitonin value was then compared with the level of amputation at the final surgical intervention. A highly statistically significant difference was found when comparing those who underwent a below-the-knee or above-the-knee amputation (median procalcitonin 1.72 ng/mL) and those who did not (median procalcitonin 0.105 ng/mL; p < .001). Therefore, patients with higher initial procalcitonin values were more likely to undergo below-the-knee or above-the-knee amputation or require aggressive surgical intervention. Thus, the procalcitonin level can provide valuable initial information to the clinician.
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Affiliation(s)
- Matthew M Reiner
- Resident, Postgraduate Year 2, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH.
| | - Wissam E Khoury
- Program Director, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH
| | - Michael B Canales
- Chief, Division of Podiatry, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH
| | | | - Kartick Patel
- Resident, Postgraduate Year 1, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH
| | - Mark C Razzante
- Resident, Postgraduate Year 2, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH
| | - Coleman O Cloughtery
- Resident, Postgraduate Year 2, Podiatric Surgical Residency, St. Vincent Charity Medical Center, Cleveland, OH
| | - Douglas Y Rowland
- Adjunct Faculty, Department of Epidemiology and Biostatistics, Case Western Reserve University School of Medicine, Cleveland, OH
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Columbo JA, Nolan BW, Stucke RS, Rzucidlo EM, Walker KL, Powell RJ, Suckow BD, Stone DH. Below-Knee Amputation Failure and Poor Functional Outcomes Are Higher Than Predicted in Contemporary Practice. Vasc Endovascular Surg 2016; 50:554-558. [PMID: 27909207 DOI: 10.1177/1538574416682159] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The perceived functional benefit of below-knee amputation (BKA) must be carefully weighed against the need for potential reinterventions. This study sought to examine the contemporary clinical and functional outcomes of patients undergoing BKA in the endovascular era. METHODS All patients who underwent BKA from January 2008 to December 2014 at a single tertiary medical center were retrospectively reviewed. Demographics, comorbidities, ambulation status, and transcutaneous oximetry (TcPO2) values were recorded. Study end points included freedom from conversion to above-knee amputation (AKA), freedom from conversion to AKA or death, BKA healing, and ambulation. Statistical modeling was performed to determine associations with BKA failure. RESULTS Over the study interval, 130 limbs underwent BKA in 120 patients. Transcutaneous oximetry studies were obtained in 65% (n = 85). Thirty-eight percent (n = 46) of all BKA patients went on to heal and ambulate. Twenty-five percent (n = 33) required reintervention, 24 with conversion to AKA, and 9 with BKA revision. One-year freedom from conversion to AKA was 76% and was decreased among those with lower TcPO2 levels (60% TcPO2 <40 vs 81% TcPO2 ≥40; P = .04). One-year composite freedom from conversion to AKA/death was 60% and was decreased among those with lower TcPO2 readings (39% TcPO2 <40 vs 69% TcPO2 ≥40; P = .01). CONCLUSION Despite a perceived functional bias toward knee salvage at the time of major amputation, most patients failed to postoperatively ambulate. Those with decreased TcPO2 levels (<40 mm Hg) have a 2-fold higher risk of AKA conversion or death, while nearly one-fourth of all BKA patients will succumb to the same fate irrespective of TcPO2. This suggests that many BKA patients in the endovascular era fail to derive the perceived benefit of knee salvage at the time of their index amputation. These findings highlight the need for careful patient selection and for a shared decision-making model in this frail population.
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Affiliation(s)
- Jesse A Columbo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Brian W Nolan
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Ryland S Stucke
- 2 Department of General Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Eva M Rzucidlo
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Karen L Walker
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Richard J Powell
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Bjoern D Suckow
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David H Stone
- 1 Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Lozano-Alonso S, Linares-Palomino JP, Vera-Arroyo B, Bravo-Molina A, Hernández-Quero J, Ros-Díe E. Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores. Enferm Infecc Microbiol Clin 2016; 34:477-83. [DOI: 10.1016/j.eimc.2015.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/06/2015] [Accepted: 10/13/2015] [Indexed: 11/27/2022]
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Forsythe RO, Hinchliffe RJ. Assessment of foot perfusion in patients with a diabetic foot ulcer. Diabetes Metab Res Rev 2016; 32 Suppl 1:232-8. [PMID: 26813616 DOI: 10.1002/dmrr.2756] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Assessment of foot perfusion is a vital step in the management of patients with diabetic foot ulceration, in order to understand the risk of amputation and likelihood of wound healing. Underlying peripheral artery disease is a common finding in patients with foot ulceration and is associated with poor outcomes. Assessment of foot perfusion should therefore focus on identifying the presence of peripheral artery disease and to subsequently estimate the effect this may have on wound healing. Assessment of perfusion can be difficult because of the often complex, diffuse and distal nature of peripheral artery disease in patients with diabetes, as well as poor collateralisation and heavy vascular calcification. Conventional methods of assessing tissue perfusion in the peripheral circulation may be unreliable in patients with diabetes, and it may therefore be difficult to determine the extent to which poor perfusion contributes to foot ulceration. Anatomical data obtained on cross-sectional imaging is important but must be combined with measurements of tissue perfusion (such as transcutaneous oxygen tension) in order to understand the global and regional perfusion deficit present in a patient with diabetic foot ulceration. Ankle-brachial pressure index is routinely used to screen for peripheral artery disease, but its use in patients with diabetes is limited in the presence of neuropathy and medial arterial calcification. Toe pressure index may be more useful because of the relative sparing of pedal arteries from medial calcification but may not always be possible in patients with ulceration. Fluorescence angiography is a non-invasive technique that can provide rapid quantitative information about regional tissue perfusion; capillaroscopy, iontophoresis and hyperspectral imaging may also be useful in assessing physiological perfusion but are not widely available. There may be a future role for specialized perfusion imaging of these patients, including magnetic resonance imaging techniques, single-photon emission computed tomography and PET-based molecular imaging; however, these novel techniques require further validation and are unlikely to become standard practice in the near future.
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Affiliation(s)
- Rachael O Forsythe
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Robert J Hinchliffe
- St George's Vascular Institute, St James Wing, St George's Hospital, London, UK
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Montero-Baker MF, Au-Yeung KY, Wisniewski NA, Gamsey S, Morelli-Alvarez L, Mills JL, Campos M, Helton KL. The First-in-Man "Si Se Puede" Study for the use of micro-oxygen sensors (MOXYs) to determine dynamic relative oxygen indices in the feet of patients with limb-threatening ischemia during endovascular therapy. J Vasc Surg 2015; 61:1501-9.e1. [PMID: 26004327 DOI: 10.1016/j.jvs.2014.12.060] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/20/2014] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Patients with limb-threatening ischemia exhibit uneven patterns of perfusion in the foot, which makes it challenging to determine adequate topographic perfusion by angiography alone. This study assessed the feasibility of reporting dynamic relative oxygen indices and tissue oxygen concentration from multiple locations on the foot during endovascular therapy using a novel micro-oxygen sensor (MOXY; PROFUSA, Inc, South San Francisco, Calif) approach. METHODS A prospective, 28-day, single-arm, observational study was performed in 10 patients who underwent endovascular therapy for limb-threatening ischemia. At least 24 hours before therapy, four microsensors were injected in each patient (one in the arm, three in the treated foot). The optical signal from the microsensors corresponded to tissue oxygen concentration. A custom detector on the surface of the skin was used to continuously and noninvasively measure the signals from the microsensors. The ability to locate and read the signal from each injected microsensor was characterized. Oxygen data from the microsensors were collected throughout the revascularization procedure. The timing of therapy deployment was recorded during the procedure to assess its relationship with the microsensor oxygen data. Oxygen data collection and clinical evaluation were performed immediately postoperatively as well as postoperatively on days 7, 14, 21, and 28. RESULTS The study enrolled 10 patients (50% male) with ischemia (30% Rutherford class 4, 70% Rutherford class 5). Patients were a mean age of 70.7 years (range, 46-90 years), and all were Hispanic of varying origin. Microsensors were successfully read 206 of 212 times (97.2%) in all patients during the course of the study. Microsensors were compatible with intraoperative use in the interventional suite and postoperatively in an office setting. In nine of 10 revascularization procedures, at least one of the three MOXYs showed an immediate change in the dynamic relative oxygen index, correlating to deployed therapy. Moreover, there was a statistically significant increase in the concentration of oxygen in the foot in preoperative levels compared with postoperative levels. No adverse events occurred related to the microsensor materials. CONCLUSIONS This MOXY approach appears to be safe when implanted in patients with limb-threatening ischemia undergoing endovascular recanalization and is effective in reporting local tissue oxygen concentrations over a course of 28 days. Further testing is needed to determine its potential effect on clinical decision making, both acutely on-table and chronically as a surveillance modality, which ultimately can lead to improved healing and limb salvage.
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Affiliation(s)
- Miguel F Montero-Baker
- Division of Vascular and Endovascular Surgery, University of Arizona, Tucson, Ariz; Pima Vascular Group, Tucson, Ariz.
| | - Kit Yee Au-Yeung
- Product Development Division, PROFUSA, Inc, South San Francisco, Calif
| | | | - Soya Gamsey
- Research & Development Division, PROFUSA, Inc, South San Francisco, Calif
| | - Luis Morelli-Alvarez
- Center of Academic Excellence in Endovascular Therapy (CEATE) Foundation, San José, Costa Rica
| | - Joseph L Mills
- Division of Vascular and Endovascular Surgery, University of Arizona, Tucson, Ariz
| | - Marianella Campos
- Center of Academic Excellence in Endovascular Therapy (CEATE) Foundation, San José, Costa Rica
| | - Kristen L Helton
- Product Development Division, PROFUSA, Inc, South San Francisco, Calif
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Benitez E, Sumpio BJ, Chin J, Sumpio BE. Contemporary assessment of foot perfusion in patients with critical limb ischemia. Semin Vasc Surg 2014; 27:3-15. [PMID: 25812754 DOI: 10.1053/j.semvascsurg.2014.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Significant progress in limb salvage for patients with peripheral arterial disease and critical limb ischemia has occurred in the past 2 decades. Improved patient outcomes have resulted from increased knowledge and understanding of the disease processes, as well as efforts to improve revascularization techniques and enhance patient care after open and endovascular procedures. An imaging modality that is noninvasive, fast, and safe would be a useful tool for clinicians in assessing lower-extremity perfusion when planning interventions. Among the current and emerging regional perfusion imaging modalities are transcutaneous oxygen monitoring, hyperspectral imaging, indocyanine green dye-based fluorescent angiography, nuclear diagnostic imaging, and laser Doppler. These tests endeavor to delineate regional foot perfusion to guide directed revascularization therapy in patients with critical limb ischemia and foot ulceration.
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Affiliation(s)
- Erik Benitez
- Department of Vascular Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Brandon J Sumpio
- Department of Vascular Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Jason Chin
- Department of Vascular Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510
| | - Bauer E Sumpio
- Department of Vascular Surgery, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510.
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Bajwa A, Wesolowski R, Patel A, Saha P, Ludwinski F, Smith A, Nagel E, Modarai B. Assessment of tissue perfusion in the lower limb: current methods and techniques under development. Circ Cardiovasc Imaging 2014; 7:836-43. [PMID: 25227236 DOI: 10.1161/circimaging.114.002123] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Adnan Bajwa
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Roman Wesolowski
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Ashish Patel
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Prakash Saha
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Francesca Ludwinski
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Alberto Smith
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Eike Nagel
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.)
| | - Bijan Modarai
- From the Cardiovascular Division, Academic Department of Surgery, Kings College London, BHF Centre of Research Excellence & NIHR Biomedical Research Centre at Kings Health Partners, St Thomas' Hospital, London, United Kingdom (A.B., A.P., P.S., F.L., A.S., B.M.); and Division of Imaging Sciences and Biomedical Engineering. Department of Cardiovascular Imaging, Kings College London, BHF Centre of Research Excellence, Wellcome Trust-EPSRC Medical Engineering Centre & NIHR Biomedical Research Centre at Kings Health Partners, St. Thomas' Hospital, London, United Kingdom (R.W., E.N.).
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worsley P, Voegeli D. Back to basics: biophysical methods in tissue viability research. J Wound Care 2013; 22:434-6, 438-9. [DOI: 10.12968/jowc.2013.22.8.434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- P. worsley
- Continence technology and skin Health Cluster, Faculty of Health sciences, university of southampton, UK
| | - D. Voegeli
- Continence technology and skin Health Cluster, Faculty of Health sciences, university of southampton, UK
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Georgakarakos E, Charalampidis D, Kakagia D, Georgiadis GS, Lazarides MK, Papanas N. Current achievements with topical negative pressure to improve wound healing in dehiscent ischemic stumps of diabetic patients: a case series. INT J LOW EXTR WOUND 2013; 12:138-45. [PMID: 23667104 DOI: 10.1177/1534734613483769] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Negative pressure wound therapy has been increasingly used either as a primary or as an adjunctive therapeutic measure to treat a variety of recalcitrant wounds during the past years. It is thought to act by creating a local environment that promotes cell proliferation, angiogenesis, and granulation tissue formation, leading to accelerated wound healing to the point of spontaneous closure or reducing the wound size to facilitate significantly further surgical reconstruction. This case series presents our preliminary experience with the use of a Topical Negative Pressure system in the treatment of challenging ischemic wounds of diabetic patients. It aims to underscore its beneficial effects and explore its potential role in the management of ischemic amputated stumps to avoid ipsilateral re-amputation at a higher level.
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Affiliation(s)
- Efstratios Georgakarakos
- Department of Vascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Greece.
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