Regional variation in lower extremity revascularization and amputation for peripheral artery disease

OBJECTIVE

The aim of this study was to quantify the recent and historical extent of regional variation in revascularization and amputation for peripheral artery disease (PAD).

METHODS

This was a repeated cross-sectional analysis of all Ontarians aged 40 years or greater between 2002 and 2019. The co-primary outcomes were revascularization (endovascular or open) and major (above-ankle) amputation for PAD. For each of 14 health care administrative regions, rates per 100,000 person-years (PY) were calculated for 6-year time periods from the fiscal years 2002 to 2019. Rates were directly standardized for regional demographics (age, sex, income) and comorbidities (congestive heart failure, diabetes, chronic obstructive pulmonary disease, chronic kidney disease). The extent of regional variation in revascularization and major amputation rates for each time period was quantified by the ratio of 90th over the 10th percentile (PRR).

RESULTS

In 2014 to 2019, there were large differences across regions in demographics (rural living [range, 0%-39.4%], lowest neighborhood income quintile [range, 10.1%-25.5%]) and comorbidities (diabetes [range, 14.2%-22.0%], chronic obstructive pulmonary disease [range, 7.8%-17.9%]), and chronic kidney disease [range, 2.1%-4.0%]. Standardized revascularization rates ranged across regions from 52.6 to 132.6/100,000 PY and standardized major amputation rates ranged from 10.0 to 37.7/100,000 PY. The extent of regional variation was large (PRR ≥2.0) for both revascularization and major amputation. From 2002-2004 to 2017-2019, the extent of regional variation increased from moderate to large for revascularization (standardized PRR, 1.87 to 2.04) and major amputation (standardized PRR, 1.94 to 3.07).

CONCLUSIONS

Significant regional differences in revascularization and major amputation rates related to PAD remain after standardizing for regional differences in demographics and comorbidities. These differences have not improved over time.

Population-Based Trends in Amputations and Revascularizations for Peripheral Artery Disease From 1990 to 2009

OBJECTIVE

To determine trends in amputations and revascularizations for peripheral artery disease (PAD) in a well-defined population.

METHODS

A population-based cohort study of Olmsted County, Minnesota, residents with PAD undergoing amputation or revascularization was conducted between January 1, 1990, and December 31, 2009. Population-level 5-year incidence trends for endovascular, open surgical, and hybrid revascularizations and major and minor amputations were determined. Limb-specific outcomes after revascularization, including major adverse limb events and amputation-free survival, were compared between initial surgical and endovascular or hybrid revascularization groups using Kaplan-Meier analysis.

RESULTS

We identified 773 residents who underwent 1906 limb-procedures, including 689 open revascularizations, 685 endovascular or hybrid revascularizations, and 220 major amputations. During the 20-year study period, the incidence of endovascular and hybrid revascularizations increased, whereas the incidence of open surgical revascularizations and major amputations decreased. Incidence of revascularizations for chronic limb-threatening ischemia (CLTI) did not change. Among residents with CLTI undergoing their first revascularization on a limb, endovascular revascularization was associated with more major adverse limb events and major amputations compared with surgical revascularization during the ensuing 15 years.

CONCLUSION

The rising incidence of endovascular and hybrid revascularizations and the decreasing incidence of open surgical revascularizations for PAD were associated with a decreasing incidence of major amputations in this population between 1990 and 2009, despite a stable incidence of revascularizations for CLTI. With more major adverse limb events and major amputations after endovascular revascularization, these trends suggest that additional emphasis should be placed on improving limb salvage efforts beyond just mode of revascularization.

Role of miRNAs in diabetic neuropathy: mechanisms and possible interventions

Accelerating cases of diabetes worldwide have given rise to higher incidences of diabetic complications. MiRNAs, a much-explored class of non-coding RNAs, play a significant role in the pathogenesis of diabetes mellitus by affecting insulin release, β-cell proliferation, and dysfunction. Besides, disrupted miRNAs contribute to various complications, diabetic retinopathy, nephropathy, and neuropathy as well as severe conditions like diabetic foot. MiRNAs regulate various processes involved in diabetic complications like angiogenesis, vascularization, inflammations, and various signaling pathways like PI3K, MAPK, SMAD, and NF-KB signaling pathways. Diabetic neuropathy is the most common diabetic complication, characterized mainly by pain and numbness, especially in the legs and feet. MiRNAs implicated in diabetic neuropathy include mir-9, mir-106a, mir-146a, mir-182, miR-23a and b, miR-34a, and miR-503. The diabetic foot is the most common diabetic neuropathy, often leading to amputations. Mir-203, miR-23c, miR-145, miR-29b and c, miR-126, miR-23a and b, miR-503, and miR-34a are associated with diabetic foot. This review has been compiled to summarize miRNA involved in initiation, progression, and miRNAs affecting various signaling pathways involved in diabetic neuropathy including the diabetic foot. Besides, potential applications of miRNAs as biomarkers and therapeutic targets in this microvascular complication will also be discussed.

Are Readmission and Reoperation Rates for Lower Extremity Necrotizing Fasciitis Different Between Patients With and Without Diabetes Mellitus?

Necrotizing fasciitis is a condition associated with high morbidity and mortality unless emergent surgery is performed. This study aims to understand the hospital course of diabetic and nondiabetic patients managed for lower-extremity necrotizing fasciitis by identifying factors contributing to readmissions and reoperations. About 562 patients treated for lower-extremity necrotizing fasciitis were selected from the American College of Surgeons-National Surgical Quality Improvement Program database between 2012 and 2017. The unplanned reoperation and readmission rates for all patients during the 30-day postoperative period were 9.4% and 5.3%, respectively. Out of 562 patients with lower-extremity necrotizing fasciitis, 326 (58.0%) patients had diabetes. Diabetes patients were more likely to undergo amputation (p < .00001). Neither readmission (6.1% vs 4.2%, p = .411) nor reoperation (8.6% vs 10.6%, p = .482) were significantly different between patients with and without diabetes. Neither readmission (7.2% vs 4.0%, p = .159) nor reoperation (4.1% vs 3.7%, p = .842) were significantly different between patients undergoing amputation and nonamputation procedures. In simple logistic regression, factors associated with unplanned reoperation included poorer renal function, thrombocytopenia, longer duration of surgery, longer hospital length of stay, postoperative surgical site infection, postoperative respiratory distress, and postoperative septic shock. Body mass index >30 kg/m² was associated with decreased odds of readmission. In multiple logistic regression, surgical site infection was the only predictor of reoperation (adjusted odds ratio 7.32, 95% confidence interval 2.76-19.1), and any amputation was associated with readmission (adjusted odds ratio 4.53, 95% confidence interval 1.20-29.6). Further study is needed to understand patient characteristics to better direct management. However, the current study elucidates patient outcomes for a relatively rare condition.

Characterizing palliative care needs in people with or at risk of developing diabetic foot ulcers

AIMS

Diabetic foot ulcers (DFUs) have a significant impact on a patient's quality of life and life expectancy, with mortality rates comparable with malignant diseases. However, there is a lack of data regarding palliative care needs in this population. We aimed to characterize palliative care needs in people under diabetic foot surveillance using the Integrated Palliative care Outcome Scale (IPOS) and EuroQol-5D three-level version (EQ-5D-3L) and to assess differences between those with and without a DFU.

METHODS

We conducted a cross-sectional study with consecutive sampling inclusion of patients followed in a tertiary hospital's Diabetic Foot Clinic between February and October 2019 with (n = 20) and without (n = 42) active DFU.

RESULTS

The most frequent symptoms encountered were pain, weakness or lack of energy, sore or dry mouth and drowsiness. Patients with an active DFU were significantly more likely to report feeling anxious or worried in comparison with those without (95% versus 55%, p = 0.002). Only 10% of the participants with an active DFU said that they were always able to share how they felt with family and friends as much as they wanted in comparison with 45% of those without (p = 0.006).

CONCLUSION

Our study identified palliative care needs in patients under diabetic foot surveillance with and without DFU, including a significant presence of physical symptoms. Patients in both groups showed signs of emotional/psychological distress, with a higher manifestation in patients with DFU. To the best of our knowledge, this is the first study addressing and characterizing palliative care needs in this population.

Palliative Care Interventions for Peripheral Artery Disease: A Systematic Review and Narrative Synthesis

Background: Peripheral artery disease (PAD) encompasses conditions with poor outcome and severe suffering, both mentally and physically, yet utilization and research into palliative care interventions remain sparse. Objective: The purpose of this study is to identify existing evidence on palliative care intervention for chronic limb threatening ischaemia (CLTI) and abdominal aortic aneurysm (AAA). Design: We conducted a PROSPERO-registered systematic review of studies published between 1991 and 2020 in which people with PAD received palliative care interventions and at least one patient outcome was recorded. For the purpose of this study, a palliative care intervention was defined as one which aims primarily to reduce negative impact of PAD on patients' and/or caregivers' physical, emotional, psychological, social, or spiritual condition. Results: A total of 8 studies involving 87,024 patients met the inclusion criteria (4 cohort studies and 4 cross-sectional studies). Methodological quality ranged from low to moderate. The small number of studies and study heterogeneity precluded meta-analysis. Regarding our primary outcomes, only two articles recorded patient-reported outcomes. Five articles found an association between palliative care and reduction in health care utilization, a secondary outcome of the study. Most of the studies reported that palliative care was likely underused. Only two of the studies included non-hospital patients. Conclusion: Despite high mortality and morbidity associated with PAD, evidence of the effectiveness of palliative care in this group of patients is lacking. There are only a handful of articles on palliative care for people with PAD, and the majority are small, methodologically flawed and lack meaningful patient-reported outcomes. High-quality research of palliative care interventions in patients with PAD is urgently needed to better understand the impact of palliative care on quality of end of life and to develop and evaluate service-level interventions.

Deferring Amputation in Diabetic Foot Osteomyelitis: Doing More Harm Than Good?

In a cohort of patients with diabetic foot osteomyelitis who were recommended to undergo below-knee amputation, those who deferred amputation and chose medical therapy were more likely to die during the follow-up time compared with those who proceeded with amputation.

Depression in diabetic foot ulcer: Associated factors and the impact of perceived social support and anxiety on depression

Diabetic foot ulcer (DFU) exerts a heavy physical and emotional burden on patients with diabetes mellitus. The purpose of the present study was to explore the impact of anxiety and perceived social support on depression of DFU patients well as patients' characteristics associated with depression. The sample of the study consisted of 180 DFU patients. Data collected by the completion of "Self-rating Depression/Anxiety Scale- Zung" (SDS/SAS) and the Multidimensional Scale of Perceived Social Support (MSPSS). Patients had moderate levels of anxiety and depression (median: 36, 42, respectively) and high levels of perceived social support from their significant ones, their family and friends (median: 24, 24, 17, respectively). After multiple regression factors that were found to have an impact on depression after taking into account all other factors, were patient's age of above 70 years, patient's anxiety and the social support they received from their significant ones. More specifically, patients aged above 70 years had 9.51 points higher depression than patients aged <50 years of age (β = 9.51, 95% CI: [0.76, 18.25], P = .034). Moreover, one point increase in patient's anxiety score indicated an increase of 0.71 points in patient's depression (β = 0.71, 95% CI: [0.43, 1.00], P = .001). On the contrary, one point increase in patient's social support from their significant ones indicated a decrease of 1.52 points in patient's depression (β = -1.52, 95% CI: [-0.25, -2.79], P = .020). Clinically, a better understanding of factors having an impact on depression on DFU may provide an essential in planning cost effective interventions.

Evidence-Based Gardening: Using Palliative Approaches to Cure Complex Wounds

Complex wounds are commonly thought to require aggressive surgical intervention to achieve healing. However, optimal healing results can often be achieved when greater emphasis is placed on optimizing patient factors prior to any surgical intervention. A retrospective review was performed of pressure ulcers and complex wound cases treated over 5 years at the Yale New Haven Wound Center. Optimal healing including clinical resolution of osteomyelitis and improved scarring was achieved when patient factors, such as glucose control and nutrition, were optimized. Surgical intervention can be more effective and even avoided entirely with the appropriate focus on optimizing patient factors.

Association of State and Trait Anxiety Between Patients Who Had Undergone Traumatic Amputation and Their Family Caregivers

The purpose of this research was to explore the association between state and trait anxiety experienced by patients who had undergone traumatic amputation and their family caregivers. The sample studied consisted of 50 hospitalized patients who had undergone traumatic amputation and 50 family caregivers. The collected data included patients' and caregivers' characteristics and the State Trait Anxiety Inventory scores. Fifty percent of patients and caregivers scored below 50 and 47, respectively (median), in trait anxiety. In terms of state anxiety, at least 50% of patients and caregivers scored below 56 and 50.5, respectively. These values indicate moderate to high levels of the impact of amputation on the trait and state anxiety of amputees and their caregivers. A positive linear correlation was found between the trait and state anxiety of the patients as well as between the trait and state anxiety of caregivers, as expected (ρ = 0.915, P < .001, and ρ = 0.920, P < .001, respectively). A statistically significant positive correlation was also observed between state patient anxiety and state anxiety of caregivers (ρ = 0.239 and P = .039) and between trait patient anxiety and trait anxiety of caregivers (ρ = 0.322 and P = .030). More specifically, as the patient's anxiety score (either trait temporary) increases, the score of the caregivers' anxiety increases and vice versa. Nurses should be aware of the association between anxiety of amputees and caregivers and, therefore, work in multidisciplinary teams to maximize clinical outcomes for patients after amputation and their families.

Long-Term Wound Palliation to Manage Exposed Hardware in the Setting of Peripheral Arterial Disease

Exposed orthopedic hardware in the lower extremity complicated by peripheral arterial disease typically demands multiple operative procedures by several disciplines to maintain skeletal integrity and achieve complete wound healing. For ambulatory patients that are either not candidates for lower extremity revascularization or prefer not to pursue surgical attempts at limb preservation, wound palliation is a potential management strategy. We discuss a patient with a history of severe peripheral arterial disease and a left pilon fracture previously treated with open reduction and internal fixation. He presented with a 2-month history of open wounds and exposed hardware over his left tibia. Though he initially underwent surgical revascularization to improve circulation to his lower extremity, the arterial bypass occluded within 6 months of the operation. At that point, the patient decided to forego any additional surgical intervention, including hardware removal, in favor of local wound care and expectant management. Remarkably, the wound remained stable in size over the next 14 years, he remained ambulatory, and never developed a deep wound infection. Though palliative wound care alone is understandably not the recommended first-line therapy for managing nonhealing wounds, it may be a safe and potentially durable alternative to major lower extremity amputation when revascularization and soft-tissue coverage cannot be achieved.

Heel Wounds Predict Mortality but Not Amputation after Infrapopliteal Revascularization

BACKGROUND

Ischemic heel ulcerations are generally thought to carry a poor prognosis for limb salvage. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival (AFS) than patients with forefoot wounds.

METHODS

A retrospective chart review was performed on patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes then analyzed by initial wound classification. The primary outcome was major amputation or death.

RESULTS

Three hundred ninety-eight limbs underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P = 0.02). Heel wounds comprised 12.1% of the total with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P = 0.94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (DM) (P = 0.03) and renal insufficiency (P = 0.004). 43.1% of wounds healed within 1 year, with no difference by wound location (P = 0.30). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P = 0.81) or treatment type (P = 0.33). One- and 3-year AFS was 66.2% and 44.0% for forefoot wounds and 45.7% and 17.6% for heel wounds, respectively (P = 0.001). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of death; however, there was significant interaction such that endovascular intervention was associated with higher mortality in patients with forefoot wounds (hazard ratio 2.25, P < 0.001) but not those with heel wounds (hazard ratio 0.67, P = 0.31).

CONCLUSIONS

Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to higher mortality despite equivalent rates of amputation and wound healing and regardless of treatment modality. These patients may benefit from an endovascular-first strategy.

While Mortality Rates Differ After Dysvascular Partial Foot and Transtibial Amputation, Should They Influence the Choice of Amputation Level?

Although there is strong evidence to show that the risk of dying after transtibial amputation is higher than partial foot amputation, we are concerned by the implication that amputation level influences mortality, and that such interpretations of the evidence may be used to inform decisions about the choice of amputation level. We argue that the choice of partial foot or transtibial amputation does not influence the risk of mortality. The highest mortality rates are observed in studies with older people with more advanced systemic disease and multiple comorbidities. Studies that control for the confounding influence of these factors have shown no differences in mortality rates by amputation level. These insights have important implications in terms of how we help inform difficult decisions about amputation at either the partial foot or transtibial level, given a more thoughtful interpretation of the published mortality rates.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Retrospective study of the evolution of the incidence of non-traumatic lower-extremity amputations (2007-2013) and risk factors of reamputation

AIM

Describe the incidence of non-traumatic amputation in a Spain region and identify the risk factors associated with the level of amputation and reamputation.

METHODS

Retrospective study on non-traumatic lower-extremity amputees in a Spanish region between 2007 and 2013. A descriptive, bivariate and multivariate analysis was performed using bivariate logistic regression. Statistical significance p≤0.05, SPSS V.21.

RESULTS

495 amputations were carried out in 353 patients. 81.0% (n=286) were men, mean age 68.7±10.8 years. The most frequent levels of amputation were digital (45.9%) and above-knee (40.5%). About 30% of the patients were reamputated. The multivariate analysis revealed that the factors independently related to the need for a minor lower-extremity amputation were DM [OR 3.79 (CI 95% 2.0-7.27)], foot ulcer [OR 5.82 (CI 95% 2.24-15.11)] and previous ipsilateral amputation [OR 3.19 (CI 95% 1.21-8.42)]. The risk factors independently related to the need for reamputation were DM [OR 2.21 (CI95% 1.09-4.49)], smoking [OR 2.45 (CI95% 1.33-4.50)] and previous revascularization [OR 2.75 (CI95% 1.57-4.83)].

CONCLUSIONS

Determining the incidence of amputations in diabetic patients as an indicator of quality makes it possible for health services to be evaluated. In patients with DM the most common reamputations are minor and ipsilateral.

Treatment Failure and Leg Amputation Among Patients With Foot Osteomyelitis

We sought to identify factors associated with treatment failure and leg amputations among those patients who presented with foot osteomyelitis. Characteristics, treatments, and outcomes for all patients treated for probable or definite foot osteomyelitis (per consensus definition) between January 2011 and March 2015 were reviewed. Multivariate Cox regression models were used to identify risk factors for treatment failure (unanticipated resection of additional bone or leg amputation) and of leg amputation alone. A total of 184 episodes of foot osteomyelitis met inclusion criteria. Treatment failure occurred in 53 (28.8%) and leg amputation in 21 (11.4%). Risk factors for treatment failure included severe/unaddressed peripheral artery disease, homelessness, Pseudomonas aeruginosa or Escherichia coli bone isolates, serum albumin <2.8 mg/dL, hallux involvement, insulin therapy, 60 or more pack-years smoking, and <7 days of directed antibiotic therapy for a positive bone margin. Delayed primary wound closure (ie, staged operations) had significantly lower treatment failure risk. Unanticipated resection of bone was not associated with leg amputation. Foot osteomyelitis treatment failure is common. Various factors can help identify those at risk for treatment failure and/or leg amputation, and further studies should focused whether initial management or follow-up should change when these factors are present.

Expression of TGF-β1 and miRNA-145 in patients with diabetic foot ulcers

The aim of the present study was to investigate the expression levels of transforming growth factor (TGF)-β1 and microRNA (miRNA)-145 in patients with diabetic foot ulcers (DFUs). A total of 26 patients with DFUs requiring amputation were enrolled in the study between January 2013 and August 2014. In addition, 15 trauma patients undergoing amputation over the same time period were included as a control group. Samples were collected from the blood, the dorsalis pedis arteries and muscles of the amputated limbs. The expression levels of TGF-β1 mRNA and miRNA-145 in these samples was detected using reverse transcription-quantitative polymerase chain reaction. The expression levels of TGF-β1 protein were evaluated using western blot analysis. In comparison with the control, the protein and mRNA expression levels of TGF-β1 in the DFU patients was significantly higher in the serum and the dorsalis pedis arteries, and significantly lower in the muscles with ulcers. In contrast, the expression levels of miRNA-145 was significantly lower in the blood and the dorsalis pedis arteries, and significantly higher in the muscles with ulcers in DFU patients compared with the control. The results of the present study suggested that there exists an inverse correlation between the expression levels of miRNA-145 and TGF-β1 in patients with DFU; thus suggesting that miRNA-145 may regulate the expression of TGF-β1 in patients with DFUs.

Integrating palliative care with usual care of diabetic foot wounds

Palliative care is a philosophy and a system for deciding care and can be used alone or integrated with usual chronic disease care. Palliative care encompasses end-of-life care. Palliative care aims to enhance quality of life, optimize function and manage symptoms including early in the course of chronic diseases. The purposes of this article are to outline palliative care and discuss how it can be integrated with usual care of diabetic foot wounds. Many people with diabetes who have foot wounds also have other comorbidities and diabetes complications such as cardiovascular and renal disease and depression, which affect medicine and other treatment choices, functional status, surgical risk and quality of life. Two broad of diabetic foot disease exist: those likely to heal but who could still benefit from integrated palliative care such as managing pain and those where healing is unlikely where palliation can be the primary focus. People with diabetes can die suddenly, although the life course is usually long with periods of stable and unstable disease. Many health professionals are reluctant to discuss palliative care or suggest people to document their end-of-life care preferences. If such preferences are not documented, the person might not achieve their desired death or place of death and health professionals and families can be confronted with difficult decisions. Palliative care can be integrated with usual foot care and is associated with improved function, better quality of life and greater patient and family satisfaction.