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Meloni M, Andreadi A, Bellizzi E, Giurato L, Ruotolo V, Romano M, Bellia A, Uccioli L, Lauro D. A multidisciplinary team reduces in-hospital clinical complications and mortality in patients with diabetic foot ulcers. Diabetes Metab Res Rev 2023; 39:e3690. [PMID: 37422897 DOI: 10.1002/dmrr.3690] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/26/2023] [Accepted: 05/28/2023] [Indexed: 07/11/2023]
Abstract
AIMS The current study aims to evaluate the effectiveness of a multidisciplinary diabetic foot team (MDFT) in the management of in-patients affected by diabetic foot problems. MATERIALS AND METHODS The study was a retrospective observational study. Consecutive patients with a diabetic foot problem requiring hospitalisation were included. All patients were managed by a MDFT led by diabetologists according to the guidance. The rate of in-hospital complications (IHCs), major amputation, and survival were recorded at the end of patient's hospitalisation. IHC was defined as any new infection different from wound infection, cardiovascular events, acute renal injury, severe anaemia requiring blood transfusion, and any other clinical problem not present at the assessment. RESULTS Overall, 350 patients were included. The mean age was 67.9 ± 12.6 years, 254 (72.6%) were males, 323 (92, 3%) showed Type 2 diabetes with a mean duration of 20.2 ± 9.6 years; 224 (64%) had ischaemic diabetic foot ulcers (DFUs) and 299 (85.4%) had infected DFUs. IHCs were recorded in 30/350 (8.6%) patients. The main reasons for IHCs were anaemia requiring blood transfusion (2.8%), pneumonia (1.7%), acute kidney failure (1.1%). Patients with IHCs showed a higher rate of major amputation (13.3 vs. 3.1%, p = 0.02) and mortality (16.7 vs. 0.6%, p < 0.0001) in comparison to those without. Ischaemic heart disease (IHD) and wound duration at the assessment (>1 month) were independent predictors of IHC, whereas IHCs, heart failure, and dialysis were independent predictors of in-hospital mortality. CONCLUSIONS The multidisciplinary management of diabetic foot problems leads to an IHC rate of 8%. The risk of IHCs is higher in patients with IHD and long wound duration.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Aikaterini Andreadi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Ermanno Bellizzi
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Laura Giurato
- CTO Andrea Alesini Hospital, Division of Endocrinology and Diabetes, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Valeria Ruotolo
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Maria Romano
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
| | - Luigi Uccioli
- CTO Andrea Alesini Hospital, Division of Endocrinology and Diabetes, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico "Tor Vergata", Rome, Italy
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Seghieri G, Gualdani E, Francia P, Campesi I, Franconi F, Di Cianni G, Francesconi P. Metrics of Gender Differences in Mortality Risk after Diabetic Foot Disease. J Clin Med 2023; 12:jcm12093288. [PMID: 37176728 PMCID: PMC10179088 DOI: 10.3390/jcm12093288] [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: 03/19/2023] [Revised: 04/27/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The aim of this study was to clarify any gender differences in the mortality risk of people with DFD since patients with diabetic foot disease (DFD) are at a high risk of mortality and, at the same time, are more likely to be men. METHODS From regional administrative sources, the survival probability was retrospectively evaluated by the Kaplan-Meier method and using the Cox proportional-hazards model comparing people with DFD to those without DFD across the years 2011-2018 in Tuscany, Italy. Gender difference in mortality was evaluated by the ratio of hazard ratios (RHR) of men to women after initial DFD hospitalizations (n = 11,529) or in a cohort with prior history of DFD hospitalizations (n = 11,246). RESULTS In both cohorts, the survival probability after DFD was lower among women. Compared to those without DFD, after initial DFD hospitalizations, the mortality risk was significantly (18%) higher for men compared to women. This excess risk was particularly high after major amputations but also after ulcers, infections, gangrene, or Charcot, with a lower reduction after revascularization procedures among men. In the cohort that included people with a history of prior DFD hospitalizations, except for the risk of minor amputations being higher for men, there was no gender difference in mortality risk. CONCLUSIONS In people with DFD, the overall survival probability was lower among women. Compared to those without DFD after a first DFD hospitalization, men were at higher risk of mortality. This excess risk disappeared in groups with a history of previous DFD hospitalizations containing a greater percentage of women who were older and probably had a longer duration of diabetes and thus becoming, over time, progressively frailer than men.
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Affiliation(s)
- Giuseppe Seghieri
- Epidemiology Unit, Agenzia Regionale Sanità, 50141 Florence, Italy
- Faculty of Physiatry, University of Florence, 50121 Florence, Italy
| | - Elisa Gualdani
- Epidemiology Unit, Agenzia Regionale Sanità, 50141 Florence, Italy
| | - Piergiorgio Francia
- Department of Information Engineering, University of Florence, 50121 Florence, Italy
| | - Ilaria Campesi
- Laboratorio Nazionale di Farmacologia e Medicina di Genere, Istituto Nazionale Biostrutture Biosistemi, University of Sassari, 07100 Sassari, Italy
| | - Flavia Franconi
- Laboratorio Nazionale di Farmacologia e Medicina di Genere, Istituto Nazionale Biostrutture Biosistemi, University of Sassari, 07100 Sassari, Italy
| | - Graziano Di Cianni
- Diabetes and Metabolic Diseases Unit, Health Local Unit North-West Tuscany, 57121 Livorno, Italy
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Mortality Risk Associated with Diabetic Foot Complications in People with or without History of Diabetic Foot Hospitalizations. J Clin Med 2022; 11:jcm11092454. [PMID: 35566581 PMCID: PMC9105877 DOI: 10.3390/jcm11092454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 04/17/2022] [Accepted: 04/25/2022] [Indexed: 02/04/2023] Open
Abstract
The aim of this study was to evaluate the risk of death after hospitalizations for diabetic foot (DF) complications, comparing two different cohorts of people with or without a prior history of DF hospitalizations across the years 2011 to 2018 in Tuscany, Italy. The DF complications were categorized by administrative source datasets such as: amputations (both major and minor), gangrene, ulcers, infections, Charcot and revascularizations. A further aim was to present the trend over time of the first ever incidents of diabetic foot hospitalizations in Tuscany. The eight-year-mortality rate was higher in the cohort with prior hospitalizations (n = 6633; 59%) compared with the cohort with first incident DF hospitalizations (n = 5028; 44%). Amputations (especially major ones) and ulcers had the worst effect on survival in people without basal history of DF hospitalizations and respectively in those with a history of prior DF hospitalizations. In both cohorts, revascularization procedures, when compared to ulcers, were associated with a significantly reduced risk of mortality. The prevalence rate of minor amputations showed a slightly rising trend over time. This result agrees with the national trend. Conversely, the progressive increase over time of revascularizations, associated with the fractional decrease in the rate of gangrene, suggests a trend for more proactive behavior by DF care teams in Tuscany.
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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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Speight S, Morriss-Roberts C. What is the Lived Experience of the ‘Three Great Pathologies’ of Diabetic Foot Disease? An Interpretative Phenomenological Analysis of the Independent Thinking of Podiatrists in Diabetes Secondary Care. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2022; 59:469580221088622. [PMID: 35506676 PMCID: PMC9073104 DOI: 10.1177/00469580221088622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Researching the podiatrists’ lived experience of The Three Great Pathologies may help improve the quality of patient care. The aim of this research using an Interpretative Phenomenological Analysis approach is to report on insights relating to the Three Great Pathologies of diabetic foot disease – infection, ischaemia and amputation. To do this, data was collected from six New Zealand diabetes care Podiatrists. Three superordinate themes resulted with subordinate themes. They are compromised health status, podiatric challenges and best outcomes. The findings are firstly, patient education remains a priority; secondly, there is an unmet need for postgraduate podiatry education; and thirdly, early intervention is a key measure for reducing the influence of the Three Great Pathologies. This study demonstrates that focussing on a group of six specialist podiatrists contributes to new priorities of care for dealing with the Three Great Pathologies of diabetic foot disease.
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Affiliation(s)
- Simon Speight
- School of Health Professions, University of Brighton Faculty of Health and Social Sciences, Brighton, UK
| | - Chris Morriss-Roberts
- School of Health Professions, University of Brighton Faculty of Health and Social Sciences, Brighton, UK
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Seghieri G, Policardo L, Gualdani E, Francesconi P. Gender Differences in the Risk of Adverse Outcomes After Incident Diabetic Foot Hospitalization: A Population Cohort Study. Curr Diabetes Rev 2022; 18:e270821195904. [PMID: 34455962 DOI: 10.2174/1573399817666210827121937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 05/25/2021] [Accepted: 05/31/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic Foot Disease (DFD) is more prevalent among males and is associated with an excess risk of cardiovascular events or mortality. AIMS This study aimed at exploring the risk of cardiovascular events, renal failure, and all-cause mortality after incident DFD hospitalizations, separately in males and females, to detect any gender difference in a cohort of 322,140 people with diabetes retrospectively followed up through administrative data sources in Tuscany, Italy, over the years 2011-2018. METHODS The Hazard Ratio (HR) for incident adverse outcomes after first hospitalizations for DFD, categorized as major/minor amputations (No.=449;3.89%), lower limbs' revascularizations (LLR: No.=2854;24.75%), and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to the risk of patients having a background of DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%). RESULTS DFD incidence rate was higher among males compared to females (1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD, the overall risk of coronary artery disease was significantly associated with the male gender and of stroke with the female gender. LEAD-no proc and LLR were associated with the risk of stroke only in females, whereas they were found to be associated with the risk of coronary artery disease among females to a significantly greater extent compared to males. The incident of renal failure was not associated with any DFD category. Amputations and LEAD-no proc significantly predicted high mortality risk only in females, while LLR showed reduced risk in both genders. Moreover, females had a greater risk of composite outcomes (death or cardiovascular events). Compared to the background of DFD, the risk was found to be 34% higher after amputations (HR: 1.34(1.04-1.72)) and 10% higher after LEAD-no proc (HR:1.10(1.03-1.18)), confirming that after incident DFD associated with vascular pathogenesis, females are at an increased risk of adverse events. CONCLUSION After incident DFD hospitalizations, females with DFD associated with amputations or arterial disease are at a greater risk of subsequent adverse cardiovascular events than those with a DFD background.
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Affiliation(s)
- Giuseppe Seghieri
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Laura Policardo
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Elisa Gualdani
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
| | - Paolo Francesconi
- Department of Epidemiology Unit, Regional Health Agency of Tuscany, Florence, Italy, Via Pietro Dazzi 1, Italy
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Fagher K, Löndahl M. The combined impact of ankle-brachial index and transcutaneous oxygen pressure on mortality in patients with type 2 diabetes and foot ulcers. Acta Diabetol 2021; 58:1359-1365. [PMID: 33966109 PMCID: PMC8413169 DOI: 10.1007/s00592-021-01731-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/29/2021] [Indexed: 12/30/2022]
Abstract
AIMS A diabetic foot ulcer (DFU) is associated with increased cardiovascular risk and mortality, independently of ulcer etiology (ischemic, neuro-ischemic or neuropathic). Ankle-brachial index (ABI) is the most commonly used test when diagnosing peripheral macrovascular disease and is a well-known marker for increased cardiovascular risk. Transcutaneous oxygen pressure (TcPO2) is considered to better evaluate microvascular function and has in previous studies shown correlations with both wound healing and survival. The aim of this study was to evaluate the combined impact of a low TcPO2 (<30 mmHg) and a pathological ABI (<0.9 or ≥1.4) on three-year mortality in patients with DFU. METHODS Type 2 diabetes patients aged <90 years, with at least one DFU who underwent vascular assessment with ABI and TcPO2 were screened for participation. The primary endpoint was mortality after three years, assessed from the National Death Registry in Sweden. RESULTS The study enrolled 235 participants with a median age of 76 years. Individuals with either an abnormally high or low ABI in combination with a low TcPO2 had the worst survival rates, with three-year mortality of 54%, compared to 42% in those with one abnormal variable (either ABI or TcPO2), and 21% in those with normal ABI and TcPO2. CONCLUSIONS Combining ABI and TcPO2 when risk stratifying DFU patients seems to provide additional predictive information, not only concerning ulcer healing and limb salvage, but also on survival.
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Affiliation(s)
- Katarina Fagher
- Clinical Sciences in Lund, Lund University, Lund, Sweden.
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden.
| | - Magnus Löndahl
- Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
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Stahlberg E, Stroth A, Haenel A, Grzyska U, Wegner F, Sieren M, Horn M, Barkhausen J, Goltz JP. Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach. J Endovasc Ther 2021; 29:181-192. [PMID: 34362274 DOI: 10.1177/15266028211036480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach. MATERIALS AND METHODS Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested. RESULTS Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal-plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771-18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475-17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642-18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296-17.621) (Log-rank p=0.098). CONCLUSION Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal-plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.
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Affiliation(s)
- Erik Stahlberg
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Andreas Stroth
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Alexander Haenel
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Ulrike Grzyska
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Franz Wegner
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Malte Sieren
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Marco Horn
- Department of Surgery, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jörg Barkhausen
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Peter Goltz
- Institute for Diagnostic and Interventional Radiology/Neuroradiology, SANA Hospital, Lübeck, Germany
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Albright RH, Joseph RM, Wukich DK, Armstrong DG, Fleischer AE. Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective? Clin Orthop Relat Res 2020; 478:2869-2888. [PMID: 32694315 PMCID: PMC7899431 DOI: 10.1097/corr.0000000000001416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE Level II, economic and decision analysis.
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Affiliation(s)
- Rachel H Albright
- R. H. Albright, The Dartmouth Institute, Geisel School of Medicine, Hanover, NH, USA
| | - Robert M Joseph
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Dane K Wukich
- D. K. Wukich, Department of Orthopaedic Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - David G Armstrong
- D. G. Armstrong, Southwestern Academic Limb Salvage Alliance, Department of Surgery, Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Adam E Fleischer
- R. M. Joseph, A. E. Fleischer, Department of Podiatric Medicine and Radiology, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- A. E. Fleischer, Weil Foot and Ankle Institute, Mount Prospect, IL, USA
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Kim TI, Vartanian SS, Schneider PA. A Review and Proposed Classification System for the No-Option Patient With Chronic Limb-Threatening Ischemia. J Endovasc Ther 2020; 28:183-193. [PMID: 33032494 DOI: 10.1177/1526602820963911] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing, but poorly defined subset of patients with chronic limb-threatening ischemia (CLTI) have "no option" for revascularization. One notable subgroup includes patients with severe ischemia and advanced pedal artery occlusive disease, termed "desert foot," who are at high risk for major amputation due to a lack of conventional revascularization options. Although new therapies are being developed for no-option patients with desert foot anatomy, this subgroup and the broader group of no-option patients are not well defined, limiting the ability to evaluate outcomes. Based on a systematic review, a classification of the no-option CLTI patient was constructed for use in clinical practice and studies. Several no-option conditions were identified, including type I-severe and pedal occlusive disease (desert foot anatomy) for which there is no accepted method of repair; type II-lack of suitable venous conduit for bypass in the setting of an acceptable target for bypass; type III-extensive tissue loss with exposure of vital structures that renders salvage impossible; type IV-advanced medical comorbidities for which available revascularization options would pose a prohibitive risk; and type V-presence of a nonfunctional limb. While type I and type II patients may have no option for revascularization, type III and type V patients have wounds, infection, comorbidities, or functional status that may leave them with few options for revascularization. As treatment strategies continue to evolve and novel methods of revascularization are developed, the ability to identify no-option patients in a standardized fashion will aid in treatment selection and assessment of outcomes.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Shant S Vartanian
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California at San Francisco School of Medicine, San Francisco, CA, USA
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11
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Dalla Paola L, Cimaglia P, Carone A, Scavone G, Boscarino G, Bernucci D, Sbarzaglia P, Censi S, Ferrari R, Campo G. Limb salvage in diabetic patients with no-option critical limb ischemia: outcomes of a specialized center experience. Diabet Foot Ankle 2019; 10:1696012. [PMID: 31839898 PMCID: PMC6896489 DOI: 10.1080/2000625x.2019.1696012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 11/13/2019] [Indexed: 12/21/2022]
Abstract
Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot lesions (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with a diagnosis of DF and CLI. All patients were followed-up for at least 1 year and/or total recovery. The primary endpoint was 1-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At 1 year, AFS, limb salvage, and survival rates were 34%, 34%, and 83%, respectively. Lesions located proximal to the Lisfranc joint were associated with major amputation (HR 2.1 [1.2–3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log-rank p = 0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02–59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had a greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival.
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Affiliation(s)
- Luca Dalla Paola
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy.,Cardiovascular Center, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Paolo Cimaglia
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy.,Cardiovascular Center, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Anna Carone
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy
| | - Giuseppe Scavone
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy
| | - Giulio Boscarino
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy
| | - Davide Bernucci
- Cardiovascular Center, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Paolo Sbarzaglia
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy
| | - Stefano Censi
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy
| | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy.,Cardiovascular Center, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
| | - Gianluca Campo
- Maria Cecilia Hospital, GVM Care & Research, E.S.: Health Science Foundation, Cotignola, Italy.,Cardiovascular Center, Azienda Ospedaliero-Universitaria di Ferrara, Cona, Italy
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12
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Pande SD, Kamal A, Zaw E, Tin AS. Patients following lower limb amputation: A retrospective cohort study showing how to improve survival and rehabilitation outcomes. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Fagher K, Katzman P, Löndahl M. Transcutaneous oxygen pressure as a predictor for short-term survival in patients with type 2 diabetes and foot ulcers: a comparison with ankle-brachial index and toe blood pressure. Acta Diabetol 2018; 55:781-788. [PMID: 29707757 PMCID: PMC6060900 DOI: 10.1007/s00592-018-1145-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 04/11/2018] [Indexed: 12/29/2022]
Abstract
AIMS Ankle-brachial index (ABI) is the most commonly used test when diagnosing peripheral vascular disease and is considered a marker for cardiovascular risk. Transcutaneous oxygen pressure (TcPO2), a test associated with microvascular function, has in several studies shown better correlation with diabetic foot ulcer (DFU) healing. Whether a low TcPO2 could be a marker for mortality in the high-risk population of DFU patients has not been evaluated before. The aim of this study was to evaluate the predictive value of TcPO2 in comparison with ABI and toe blood pressure (TBP) on 1-year mortality in type 2 diabetes patients with DFU. METHODS Type 2 diabetes patients aged ≤ 90 years, with one DFU who attended our multidisciplinary DFU-unit during year 2013-2015 and were screened with TcPO2, ABI and TBP were retrospectively evaluated. One-year mortality was assessed from the national death register in Sweden. RESULTS A total of 236 patients (30% women) with a median age of 76 (69-82) years were evaluated in this study. Within 1 year, 14.8% of the patients died. TcPO2 < 25 mmHg was associated with a higher 1-year mortality compared with TcPO2 ≥ 25 mmHg (27.7 vs. 11.6%, p = 0.003). TBP and ABI did not significantly influence 1-year mortality. In a Cox regression analysis adjusted for confounders, TcPO2 was independently predicting 1-year mortality with a hazard ratio for TcPO2 < 25 mmHg of 2.8 (95% CI 1.34-5.91, p = 0.006). CONCLUSIONS This study indicates that a low TcPO2 is an independent prognostic marker for 1-year mortality among patients with type 2 diabetes and DFU.
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Affiliation(s)
- K Fagher
- Clinical Sciences in Lund, Lund University, Lund, Sweden.
- Department of Endocrinology, Skåne University Hospital, 22185, Lund, Sweden.
| | - P Katzman
- Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, 22185, Lund, Sweden
| | - M Löndahl
- Clinical Sciences in Lund, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, 22185, Lund, Sweden
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14
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Zhong A, Li G, Wang D, Sun Y, Zou X, Li B. The risks and external effects of diabetic foot ulcer on diabetic patients: A hospital-based survey in Wuhan area, China. Wound Repair Regen 2017; 25:858-863. [PMID: 29052949 DOI: 10.1111/wrr.12589] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/18/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Aimei Zhong
- Department of Plastic Surgery; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
| | - Gongchi Li
- Department of Hand Surgery; Union Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
| | - Dan Wang
- Department of Wound Repair Surgery; Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
| | - Yi Sun
- School of Public Health; Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
| | - Xinghua Zou
- Department of Wound Repair Surgery; Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
| | - Binghui Li
- Department of Wound Repair Surgery; Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology; Wuhan China
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15
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Liasis L, Malietzis G, Galyfos G, Athanasiou T, Papaconstantinou HT, Sigala F, Zografos G, Filis K. The emerging role of microdialysis in diabetic patients undergoing amputation for limb ischemia. Wound Repair Regen 2016; 24:1073-1080. [PMID: 27733016 DOI: 10.1111/wrr.12492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/11/2016] [Indexed: 01/21/2023]
Abstract
Lower limb ischemia in diabetic patients is a result of macro- and microcirculation dysfunction. Diabetic patients undergoing limb amputation carry high mortality and morbidity rates, and decision making concerning the level of amputation is critical. Aim of this study is to evaluate a novel microdialysis technique to monitor tissue microcirculation preoperatively and predict the success of limb amputation in such patients. Overall, 165 patients with type 2 diabetes mellitus undergoing lower limb amputation were enrolled. A microdialysis catheter was placed preoperatively at the level of the intended flap for the stump reconstruction, and the levels of glucose, glycerol, lactate and pyruvate were measured for 24 consecutive hours. Patients were then amputated and monitored for 30 days regarding the outcome of amputation. Failure of amputation was defined as delayed healing or stump ischemia. Patients were divided into two groups based on the success of amputation. There was no difference between the two groups regarding gender, ASA score, body mass index, comorbidities, diagnostic modality used, level of amputation, as well as glucose, glycerol, and pyruvate levels. However, local concentrations of lactate were significantly different between the two groups and lactate/pyruvate (L/P) ratio was independently associated with failed amputation (threshold defined at 25.35). Elevated preoperative tissue L/P ratio is independently associated with worse outcomes in diabetic patients undergoing limb amputation. Therefore, preoperative tissue L/P ratio could be used as a predicting tool for limb amputation's outcome, although more clinical data are needed to provide safer conclusions.
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Affiliation(s)
- Lampros Liasis
- Department of Surgery, Northwick Park Hospital, Watford Road, Harrow, London, United Kingdom.,1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - George Malietzis
- Department of Surgery and Cancer, Imperial College, Paddington, London, United Kingdom
| | - George Galyfos
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College, Paddington, London, United Kingdom
| | | | - Fragiska Sigala
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Georgios Zografos
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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16
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Preoperative Predictors of 30-Day Mortality and Prolonged Length of Stay after Above-Knee Amputation. Ann Vasc Surg 2015; 31:124-33. [PMID: 26616501 DOI: 10.1016/j.avsg.2015.08.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 07/31/2015] [Accepted: 08/22/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND The above-knee amputation (AKA) is an operation of last resort with high postoperative morbidity and mortality. This study identifies preoperative risk factors predictive of both 30-day mortality and extended length of stay (LOS) in AKA patients. METHODS Two hundred ninety-five AKA patients from 2004 to 2013 from a single institution were retrospectively reviewed using a deidentified electronic medical record. Rationally selected factors potentially influencing 30-day mortality and LOS were chosen, including demographics, etiologies, vascular surgical history, lifestyle factors, comorbidities, and laboratory values. Variables trending with one of the end points on bivariate analysis (P ≤ 0.10) were entered into multivariate forward stepwise regression models to determine independence as a risk factor (P ≤ 0.05). Subgroup analysis of AKA patients without a traumatic, burn, or malignant etiology was similarly conducted. RESULTS Within the 295 patient cohort, 60% of the patients were male, 18% were African American, mean age was 58 years and mean body mass index was 28 kg/m(2). The 30-day mortality rate was 9%, and mean postoperative LOS of discharged patients was 9.3 days. Upon logistic regression, thrombocytopenia (platelet count < 250 × 10(6)/mL, P < 0.001, odds ratio 6.1) and preoperative septic shock (P = 0.02, odds ratio 5.1) were identified as independent risk factors for 30-day mortality. Upon linear regression, burn etiology (P < 0.001, B = 15.8 days), leukocytosis (white blood cell count > 12 × 10(6)/mL, P < 0.001, B = 6.2 days), and guillotine amputation (P < 0.001, B = 7.6 days) were independently associated with prolonged LOS. Excluding patients with AKAs due to trauma, burn, or malignancy, only thrombocytopenia (platelet count < 250 × 10(6)/mL, P < 0.001, odds ratio 10.2) and leukocytosis (white blood cell count > 12 × 10(6)/mL, P = 0.01, B = 5.2 days) were independent risk factors for in-hospital mortality and prolonged LOS, respectively. CONCLUSIONS Preoperative septic shock and thrombocytopenia are independent risk factors for 30-day mortality after AKA, while burn etiology, leukocytosis, and guillotine amputation contribute to prolonged LOS. Awareness of these risk factors may help enhance both preoperative decision making and expectations of the hospital admission.
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Braun L, Kim PJ, Margolis D, Peters EJ, Lavery LA. What's new in the literature: an update of new research since the original WHS diabetic foot ulcer guidelines in 2006. Wound Repair Regen 2015; 22:594-604. [PMID: 25139424 DOI: 10.1111/wrr.12220] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 05/15/2014] [Indexed: 12/15/2022]
Abstract
The objective of the paper was to update the diabetic foot ulcer guidelines that were previously published in 2006. We performed a key word search using MEDLINE and Cochrane reviews for publication between January 2006 and January 2012. Articles that fit the inclusion criteria were reviewed and the previous guidelines were updated.
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Affiliation(s)
- Liza Braun
- Department of Dermatology and Cutaneous Surgery, University of Miami, Miami, Florida
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18
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Fagher K, Nilsson A, Löndahl M. Heart rate-corrected QT interval prolongation as a prognostic marker for 3-year survival in people with Type 2 diabetes undergoing above-ankle amputation. Diabet Med 2015; 32:679-85. [PMID: 25388827 DOI: 10.1111/dme.12632] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2014] [Indexed: 12/15/2022]
Abstract
AIM To evaluate whether heart rate-corrected QT interval is a plausible prognostic factor for survival after major amputation in people with Type 2 diabetes. METHODS All people with Type 2 diabetes aged < 80 years who underwent a major amputation at two hospitals with multidisciplinary diabetic foot teams were evaluated and grouped according to whether their heart rate-corrected QT interval was ≤ or > 440 ms. RESULTS A total of 70 patients with a median age of 72 years were included in the study. During the 3 years of follow-up, 38 patients (54%) died. Heart rate-corrected QT interval prolongation was present in 51.4% of the patients and was strongly associated with 3-year mortality (73 vs 36%; P < 0.001). In a Cox proportional hazard model, heart rate-corrected QT interval prolongation was the strongest independent risk factor for 3-year mortality [hazard ratio 2.20 (95% CI 1.11-4.38)]. Treatment with metformin seemed to have a protective effect [hazard ratio 0.22 (95% CI 0.05-0.94)]. CONCLUSIONS The findings of the present study indicate that heart rate-corrected QT interval prolongation is associated with increased mortality in people with Type 2 diabetes undergoing above-ankle amputation.
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Affiliation(s)
- K Fagher
- Clinical Sciences in Lund, Lund University, Lund, Sweden; Department of Endocrinology, Skåne University Hospital, Ängelholm, Sweden
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Wei LM, Zhu YQ, Zhao JG, Wang J, Lu HT, Zhang PL. Retrograde transplantar arch angioplasty of below-the-knee arterial occlusions: outcomes compared to anterograde recanalization. Acad Radiol 2014; 21:1475-82. [PMID: 25088835 DOI: 10.1016/j.acra.2014.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 05/22/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
RATIONALE AND OBJECTIVES To compare the clinical outcomes of retrograde transplantar arch angioplasty and conventional below-the-knee (BTK) anterograde recanalization. MATERIALS AND METHODS One hundred twelve limbs in 96 patients underwent attempt at antegrade tibial angioplasty. Among 27 technical failures, retrograde trans-dorsal or -planter percutaneous transluminal angioplasty was attempted in 22 limbs. Ankle-brachial index (ABI), thrombolysis in myocardial infarction (TIMI) flow grade, and dorsal/plantar arterial pulse score improvement were compared immediately after the procedures between patients received successful anterograde angioplasty (anterograde angioplasty group [AAG], 85 limbs in 71 patients) and retrograde angioplasty (retrograde angioplasty group [RAG], 22 limbs in 20 patients). Target vessel restenosis and limb salvage were observed during follow-up. RESULTS Primary technical success rate was 75.9% in the RAG (vs. 74.0% AAG, P > .05). ABI improved from 0.55 ± 0.21 to 0.93 ± 0.19 in the RAG (vs. 0.56 ± 0.14 to 0.89 ± 0.18 AAG, P > .05). TIMI flow grade demonstrated greater reperfusion of distal foot tissue in the RAG (2.3 ± 0.8 vs. 1.0 ± 0.8, P < .05). Primary patency rates at 12 and 24 months were 63.6% (14 of 22) and 45.5% (10 of 22) in the RAG and 52.9% (45 of 85) and 37.6% (32 of 85) in the AAG, respectively (P > .05). Kaplan-Meier analysis after 24 months found limb salvage rates of 93.8% in the RAG and 96.5% in the AAG (P > .05). CONCLUSIONS Retrograde transplantar arch angioplasty achieved better immediate blood flow and similar ABI improvement, primary patency rate, and limb salvage rate compared to conventional transtibial angioplasty for BTK occlusions. This could become a supplementary technique when anterograde angioplasty fails.
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Rümenapf G, Morbach S. What can I do with a patient with diabetes and critically impaired limb perfusion who cannot be revascularized? INT J LOW EXTR WOUND 2014; 13:378-89. [PMID: 25326447 DOI: 10.1177/1534734614554283] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A patient with limb-threatening diabetic foot syndrome in whom relevant peripheral arterial occlusive disease is proven should receive arterial revascularization as soon as possible to avoid major amputation. However, 3 conditions may make it impossible to effectively restore limb perfusion: the patient will not profit from arterial revascularization owing to excessive tissue loss or sepsis ("too late"), the patient cannot be revascularized due to severe comorbidities ("too sick"), and arterial reconstruction is impossible because of technical and anatomical shortcomings in a patient who is otherwise fit for operation ("nonreconstructible limb perfusion"). This review outlines the therapeutic options specifically in the third group of patients in whom no technical option for surgical or endovascular revascularization exists.
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Affiliation(s)
- Gerhard Rümenapf
- Gefäßzentrum Oberrhein, Diakonissen-Stiftungs-Krankenhaus, Speyer, Germany
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Barnes R, Souroullas P, Lane RA, Chetter I. The Impact of Previous Surgery and Revisions on Outcome after Major Lower Limb Amputation. Ann Vasc Surg 2014; 28:1166-71. [DOI: 10.1016/j.avsg.2013.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/28/2013] [Accepted: 10/29/2013] [Indexed: 10/25/2022]
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Prevalence and 1-year course of alcohol misuse and smoking in persons with lower extremity amputation as a result of peripheral arterial disease. Am J Phys Med Rehabil 2014; 93:493-502. [PMID: 24508927 DOI: 10.1097/phm.0000000000000055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to describe prevalence of alcohol misuse and smoking among individuals with amputations as a result of peripheral arterial disease before surgery and 12 mos after surgery, changes in these behaviors over time, and factors associated with change. DESIGN This is a prospective cohort study of 75 veterans experiencing their first major unilateral amputation. Measures included demographic and general health information, Alcohol Use Disorders Identification Test, smoking behaviors, and social support. RESULTS Sixteen percent of the participants reported engaging in alcohol misuse at presurgical baseline; and 13% at 12 mos after amputation. Thirty-seven percent of the participants were categorized as smokers at baseline; this number dropped to 29% at 12 mos after amputation. Among those who decreased drinking and quit smoking, there was a trend indicating greater social support. CONCLUSIONS The participants endorsed drinking and smoking behaviors at levels consistent with other types of disability and with veterans using the Veterans Health Administration for their health care. Even with a variety of health concerns, after amputation, most of the smokers and those engaging in alcohol misuse continued to smoke and drink at their preamputation rate. The presence of social support may encourage health behavior change and is an important area for future research and intervention.
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Liao KC, Weng SF, Hsing CH, Liu C, Wang JJ, Huang KF, Chu CC. The amputation and mortality rates of diabetic patients with critical limb ischemia: A nationwide population-based follow-up study in Taiwan. FORMOSAN JOURNAL OF SURGERY 2013. [DOI: 10.1016/j.fjs.2013.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Brown BJ, Attinger CE. The Below-Knee Amputation: To Amputate or Palliate? Adv Wound Care (New Rochelle) 2013; 2:30-35. [PMID: 24527321 DOI: 10.1089/wound.2011.0317] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Indexed: 11/13/2022] Open
Abstract
SIGNIFICANCE A below-knee amputation (BKA) can be the most functional option for select patients with a diseased lower extremity and may offer a better quality of life than limb salvage in some patients. RECENT ADVANCES Because of advances in prosthetic technology, some patients may have a better quality of life with a BKA than a salvaged lower extremity. Those who cannot wear a prosthesis will do better with a poorly functioning leg. Understanding which patients will not benefit from an amputation helps ensure that a maximum of patients will continue ambulating. CRITICAL ISSUES We lack a thorough understanding of which patients will be more functional with a BKA than a salvaged extremity. Some will do better with a prosthesis, whereas others will do better with a poorly functioning peg leg. This is because so many amputees never wear their prosthesis. FUTURE DIRECTIONS A better understanding of patient selection and optimal operative technique would allow us to better council patients as to how to optimize their functional outcome. Over the past 30 years, a number of useful studies have been published regarding the BKA. However, recent advances in wound care, prosthetics, and medical care in general require a re-evaluation of the BKA within the limb salvage concept.
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Affiliation(s)
- Benjamin J. Brown
- Center for Wound Healing, Georgetown University Hospital, Washington, District of Columbia
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Georgakarakos E, Papanas N, Papadaki E, Georgiadis GS, Maltezos E, Lazarides MK. Endovascular treatment of critical ischemia in the diabetic foot: new thresholds, new anatomies. Angiology 2012; 64:583-91. [PMID: 23129734 DOI: 10.1177/0003319712465172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review discusses the role of endovascular treatment in diabetic patients with critical limb ischemia (CLI). Angioplasty of the femoropopliteal region achieves similar technical success and limb salvage rates in diabetic and nondiabetic patients. Angioplasty in as many as possible tibial vessels is accompanied by more complete and faster ulcer healing as well as better limb salvage rates compared to isolated tibial angioplasty. Targeted revascularization of a specific vessel responsible for the perfusion of a specific ulcerated area is a promising new approach: it replaces revascularization of the angiographically easiest-to-access tibial vessel, even if this is not directly responsible for the perfusion of the ulcerated area, by revascularization of area-specific vascular territories. In conclusion, the endovascular approach shows very high efficacy in ulcer healing for diabetic patients with CLI. Larger prospective studies are now needed to estimate the long-term results of this approach.
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Nason GJ, Strapp H, Kiernan C, Moore K, Gibney J, Feeley TM, Egan B, Tierney S. The cost utility of a multi-disciplinary foot protection clinic (MDFPC) in an Irish hospital setting. Ir J Med Sci 2012; 182:41-5. [PMID: 22528251 DOI: 10.1007/s11845-012-0823-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Accepted: 03/31/2012] [Indexed: 01/22/2023]
Abstract
BACKGROUND Foot ulceration which may result in lower limb amputation is one of the most feared complications among patients with diabetes and the prevention of both ulceration and amputation is a major challenge facing the health service. Many studies have proposed dedicated diabetic foot teams as the future of diabetic foot care. AIMS We aimed to quantify the cost benefit and sustainability of a multi-disciplinary foot protection clinic (MDFPC) in an Irish university hospital setting. METHODS A dedicated bi-weekly consultant-led MDFPC including Vascular Surgery, Endocrinology, Orthopaedic Surgery, Podiatry, Orthotics and Tissue Viability was established in June 2008. RESULTS Between 2006 and 2010, a total of 221 lower limb procedures (major/minor amputations and debridement) were performed. The number of major amputations decreased from 12 during the control period (2 years before the clinic) to 7 in the study period (2 years after the clinic). After costing all activity associated with the clinic, there was an overall saving of €114,063 per year associated with the introduction of the MDFPC. CONCLUSION This is the first study in an Irish context, and one of few international studies, to demonstrate that an aggressive-coordinated approach to diabetic foot care is both cost effective and clinically efficient in reducing the burden of foot-related complications in a diabetic population.
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Affiliation(s)
- G J Nason
- Department of Vascular Surgery, Adelaide and Meath (incorporating the National Children's) Hospital, Tallaght, Dublin 24, Ireland.
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Popliteo-pedal bypass surgery for critical limb ischemia. Ir J Med Sci 2011; 180:829-35. [PMID: 21800035 DOI: 10.1007/s11845-011-0740-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 07/09/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Critical limb ischaemia due to distal arterial disease represents a significant challenge. Randomised controlled evidence suggests that open surgery may be superior to endovascular intervention but there is limited data on the specific clinical cohort with exclusively infra-popliteal disease. AIM We analysed indications for, and outcome from all, popliteo-pedal bypass procedures performed between July 1998 to November 2008. PATIENTS AND METHODS Twenty-eight bypass procedures were performed in 24 patients. Autologous vein was used exclusively. The proximal anastomosis was to the below-knee popliteal artery in all the patients; the distal anastomosis was to plantar artery (n = 15) or dorsalis pedis artery (n = 13). Mean patient age was 63.Eight years of age (range 37-92 years). Indications for surgery were tissue loss (n = 21) and rest pain (n = 7). Ultrasound graft surveillance was performed every 6-months. RESULTS Using life table analysis, primary graft patency was 63.3% at 1-, 3- and 5-years and secondary patency (after three interventions) was 74.6% at 1-, 3- and 5-years. Limb salvage rate was 81.8% after 1-, 3- and 5-years as all five limb amputations were performed in the first 3-months following the surgery. Overall survival was 75, 75 and 47.1% at 1-, 3- and 5-years, respectively. The major amputation free survival rate was 54.2, 54.2 and 21.3% at 1-, 3- and 5-years, respectively. Seventy-nine percent (n = 19) patients were diabetic. CONCLUSION Our data supports popliteo-pedal bypass as an effective treatment for distal vascular disease. Comparison with endovascular treatment in a randomised trial needs to be performed.
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Contemporary Management of Diabetic Neuropathic Foot Ulceration: A Study of 917 Consecutively Treated Limbs. J Am Coll Surg 2011; 212:532-45; discussion 546-8. [DOI: 10.1016/j.jamcollsurg.2010.12.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 12/15/2010] [Indexed: 11/23/2022]
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Redlich U, Xiong YY, Pech M, Tautenhahn J, Halloul Z, Lobmann R, Adolf D, Ricke J, Dudeck O. Superiority of Transcutaneous Oxygen Tension Measurements in Predicting Limb Salvage After Below-the-Knee Angioplasty: A Prospective Trial in Diabetic Patients With Critical Limb Ischemia. Cardiovasc Intervent Radiol 2010; 34:271-9. [DOI: 10.1007/s00270-010-9968-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 07/13/2010] [Indexed: 11/29/2022]
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