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Tanda E, Ruiu G, Casula M, Lamia I, Serra A, Boscolo Meneguolo A, Zappadu S, Sanfilippo R, Camparini S, Petruzzo P. Minor amputation after revascularization in chronic limb-threatening ischemia: What is the optimal timing? Vascular 2023:17085381231214819. [PMID: 37946368 DOI: 10.1177/17085381231214819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVES Patients with chronic limb-threatening ischemia (CLTI) have a high risk of lower limb amputation and loss of walking independence. Minor amputations play a key role in ensuring walking independence and they represent a challenge in terms of timing and level for vascular surgeons. A major cause of re-amputation is a defect in wound healing and a possible predictor of re-amputation for non-healing wounds could be the incorrect timing of minor amputation after revascularization. The lack of evidence in the literature leads to a wide variability of choices in clinical practice. The purpose of this study was to try to find the optimal timing analysing the risk of re-amputation in CLTI patients who have undergone successful revascularization and minor amputation focussing on timing of minor amputation. METHODS We conducted a single centre retrospective analysis on a cohort of 151 patients consecutively admitted to our hospital for CLTI (Rutherford 5) between January 2014 and April 2022. All the enrolled patients underwent successful revascularization of lower limbs and a minor amputation for dry acral necrosis. The characteristics of the patients and the revascularization procedures were collected and analysed. Patients were divided into two groups based on the timing of minor amputation performed before (group 1) or after the day (group 2) that best predicts the risk of re-amputation according to a Receiver Operating Characteristic (ROC) curve analysis. The primary outcome of this study was the risk of re-amputation during the first 60 days of follow-up after a primary minor amputation, with revascularization still effective. The impact of the timing of minor amputation after revascularization, the type of revascularization and the presence of risk factors known to prolong the wound healing process were evaluated in a uni- and multi-variable logistic regression model. RESULTS Systemic hypertension, and type of revascularization (i.e. open vs endovascular) were independent predictors of the risk of re-amputation at 60 days (HR 4.26, 95% CI 1.30-14.04, p = .017 and HR 2.35, 95% CI 1.16-4.78, p = .018, respectively). Moreover, time ≤14 days between revascularization and first amputation was associate with a clear, albeit not statistically significant, trend toward increased risk of re-amputation (HR 2.09, 95% CI 0.97-4.51, p = .06). CONCLUSIONS In a cohort of patients who underwent a successful revascularization for CLTI and a minor amputation for dry gangrene in the first 14 days after revascularization, a higher -although not significant-risk of re-amputation was reported. In this cohort of patients, a delayed demolitive procedure should be considered to allow better tissue perfusion and to reduce the risk of re-amputation.
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Affiliation(s)
- Elisabetta Tanda
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
- Unit of Vascular Surgery, Cliniche San Pietro Hospital, AOU Sassari, Sassari, Italy
| | - Giovanni Ruiu
- Unit of Vascular Surgery, Cardiovascular Department, San Michele Hospital, ARNAS "G. Brotzu", Cagliari, Italy
| | - Matteo Casula
- Cardiology and Cardiovascular Intensive Care Unit, Cardiovascular Department, San Michele Hospital, ARNAS "G. Brotzu", Cagliari, Italy
| | - Irene Lamia
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
| | - Arianna Serra
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
| | - Anna Boscolo Meneguolo
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
| | - Sara Zappadu
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
- Unit of Vascular Surgery, Cliniche San Pietro Hospital, AOU Sassari, Sassari, Italy
| | - Roberto Sanfilippo
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
| | - Stefano Camparini
- Unit of Vascular Surgery, Cardiovascular Department, San Michele Hospital, ARNAS "G. Brotzu", Cagliari, Italy
| | - Palmina Petruzzo
- Unit of Vascular Surgery, Department of Surgical Sciences, University of Cagliari, Policlinico "D. Casula", Cagliari, Italy
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Heidari N, Charalambous A, Kwok I, Vris A, Li Y. Does Revascularization Prior to Foot and Ankle Surgery Reduce the Incidence of Surgical Site Infection (SSI)? Foot Ankle Int 2019; 40:15S-16S. [PMID: 31322950 DOI: 10.1177/1071100719859343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Several studies support the effect of peripheral vascular disease (PVD) on wound healing and surgical site infection (SSI). Despite this, there have been no specific studies proving the beneficial effect of revascularization on SSI prior to operative intervention in the setting of traumatic or elective foot and ankle surgery. The majority of studies on revascularization are in the setting of diabetic foot infection or established ischemia. We recommend that in the presence of an inadequate vascularization in the foot and ankle, vascular optimization should be undertaken prior to elective surgery. LEVEL OF EVIDENCE Limited. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Nima Heidari
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander Charalambous
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Iris Kwok
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexandros Vris
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Yueyang Li
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, UK
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Clerici G, Faglia E. Saving the Limb in Diabetic Patients With Ischemic Foot Lesions Complicated by Acute Infection. INT J LOW EXTR WOUND 2014; 13:273-93. [DOI: 10.1177/1534734614549416] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Ischemia and infection are the most important factors affecting the prognosis of foot ulcerations in diabetic patients. To improve the outcome of these patients, it is necessary to aggressively treat 2 important pathologies—namely, occlusive arterial disease affecting the tibial and femoral arteries and infection of the ischemic diabetic foot. Each of these 2 conditions may lead to major limb amputation, and the presence of both critical limb ischemia (CLI) and acute deep infection is a major risk factor for lower-extremity amputation. Thus, the management of diabetic foot ulcers requires specific therapeutic approaches that vary significantly depending on whether foot lesions are complicated by infection and/or ischemia. A multidisciplinary team approach is the key to successful treatment of a diabetic foot ulcer: ischemic diabetic foot ulcers complicated by acute deep infection pose serious treatment challenges because high levels of skill, organization, accuracy, and timing of intervention are required to maximize the chances of limb salvage: these complex issues are better managed by a multidisciplinary clinical group.
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Affiliation(s)
- Giacomo Clerici
- “Città di Pavia” University and Research Hospital Pavia, Italy
| | - Ezio Faglia
- “Città di Pavia” University and Research Hospital Pavia, Italy
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