Bypass Patency and Amputation-Free Survival after Popliteal Aneurysm Exclusion Significantly Depends on Patient Age and Medical Complications: A Detailed Dual-Center Analysis of 395 Consecutive Elective and Emergency Procedures

Background/Objectives: A popliteal artery aneurysm (PAA) is traditionally treated by an open PAA repair (OPAR) with a popliteo-popliteal venous graft interposition. Although excellent outcomes have been reported in elective cases, the results are much worse in cases of emergency presentation or with the necessity of adjunct procedures. This study aimed to identify the risk factors that might decrease amputation-free survival (efficacy endpoint) and lower graft patency (technical endpoint). Patients and Methods: A dual-center retrospective analysis was performed from 2000 to 2021 covering all consecutive PAA repairs stratified for elective vs. emergency repair, considering the patient (i.e., age and comorbidities), PAA (i.e., diameter and tibial runoff vessels), and procedural characteristics (i.e., procedure time, material, and bypass configuration). Descriptive, univariate, and multivariate statistics were used. Results: In 316 patients (69.8 ± 10.5 years), 395 PAAs (mean diameter 31.9 ± 12.9 mm) were operated, 67 as an emergency procedure (6× rupture; 93.8% severe acute limb ischemia). The majority had OPAR (366 procedures). Emergency patients had worse pre- and postoperative tibial runoff, longer procedure times, and more complex reconstructions harboring a variety of adjunct procedures as well as more medical and surgical complications (all p < 0.001). Overall, the in-hospital major amputation rate and mortality rate were 3.6% and 0.8%, respectively. The median follow-up was 49 months. Five-year primary and secondary patency rates were 80% and 94.7%. Patency for venous grafts outperformed alloplastic and composite reconstructions (p < 0.001), but prolonged the average procedure time by 51.4 (24.3-78.6) min (p < 0.001). Amputation-free survival was significantly better after elective procedures (p < 0.001), but only during the early (in-hospital) phase. An increase in patient age and any medical complications were significant negative predictors, regardless of the aneurysm size. Conclusions: A popliteo-popliteal vein interposition remains the gold standard for treatment despite a probably longer procedure time for both elective and emergency PAA repairs. To determine the most effective treatment strategies for older and probably frailer patients, factors such as the aneurysm size and the patient's overall condition should be considered.

Opioid Use Disorder in Patients Undergoing Major Lower Extremity Amputation: Prevalence and Outcomes

INTRODUCTION

Patients with a history of Opioid Use Disorder (OUD) have higher postoperative complication rates and mortality in many settings. Yet, it remains poorly understood how the opioid epidemic has affected patients undergoing major lower extremity amputation (LEA) and whether outcomes differ by OUD status.

METHODS

We conducted a retrospective chart review of all 689 patients who underwent major LEA at a large tertiary referral center from 2015 to 2021. This study assessed patient characteristics and long-term postoperative outcomes for patients with preoperative OUD.

RESULTS

133 (19.3%) patients had a lifetime history of preoperative OUD. Preoperative OUD was associated with key characteristics, comorbidities, and outcome measures. OUD was significantly associated with younger age (P < .001), black race (P = .026), single relationship status (P < .001), BMI <30 (P = .024), no primary care provider (P = .004), and Medicaid insurance (P < .001). Comorbidities significantly associated with OUD include current smoking (P < .001), Human Immunodeficiency Virus (HIV; P = .003), and history of osteomyelitis (P < .001). Preoperative OUD independently predicted lower rates of 30-60-day readmission (odds ratio [OR] .54, P = .018) and 1-12-month reamputation (OR .41, P = .006). There was no significant difference in long-term mortality and follow-up.

CONCLUSION

This study demonstrates the prevalence of OUD in patients undergoing major LEA and reports associations and long-term outcomes. Our findings highlight the importance of recognizing OUD and raise questions about the mechanisms underlying its relation to rates of postoperative readmission and reamputation.

The relationship between hyperpolypharmacy and one-year outcomes in patients with critical limb ischemia undergoing below-knee endovascular therapy

BACKGROUND

Critical limb ischemia (CLI) patients take too many medications because they are elderly and frail patients with multiple comorbidities. Polypharmacy is associated with frailty, although its prognostic significance in CLI patients is unknown. In this study, we aimed to determine the prevalence of hyperpolypharmacy among adults with CLI and its effect on 1-year amputation and mortality.

METHODS

A total of 200 patients with CLI who underwent endovascular therapy (EVT) for below-knee (CTC) lesions were included in this study. Hyperpolypharmacy was defined as using ≥10 drugs. Patients were divided into two groups according to the presence of hyperpolypharmacy.

RESULTS

We detected hyperpolypharmacy in 66 patients. The incidence of 1-year amputation [24 (36.4) versus 12 (9), p<.001] and mortality [28 (42.4) versus 12 (9), p<.001] were higher in patients with hyperpolypharmacy. Univariate and multivariate cox regression analyses were used to determine the independent predictors of amputation and mortality. In the receiver operating characteristic curve analysis, the cut-off value was defined as 10 or more drug use was able to detect the presence of 1-year mortality with 67.5% sensitivity and 79.4% specificity. The Kaplan-Meier method showed a significant difference (rank p <.001 between log groups), and hyperpolypharmacy was associated with 1-year amputation and mortality.

CONCLUSION

Hyperpolypharmacy was significantly associated with 1-year mortality and major amputation in CLI patients. Hyperpolypharmacy can be a valuable aid in patient risk assessment in the CLI.

Management of Acute Lower Limb Ischemia Without Surgical Revascularization - A Population-Based Study

OBJECTIVES

To evaluate outcomes of management without surgical revascularization in patients with acute lower limb ischemia (ALI) in a population-based setting.

DESIGN

Retrospective observational population-based study.

MATERIALS

Patients from Malmö, Sweden, hospitalized for ALI between 2015 and 2018.

METHODS

In-hospital, surgical, radiological, and autopsy registries were scrutinized for descriptive data on ALI patients managed by endovascular and open vascular surgery, conservative vascular therapy, primary major amputation, and palliative care.

RESULTS

Among 161 patients, 73 (45.3%) did not undergo any operative revascularization. Conservative vascular therapy, primary amputation, and palliative care were conducted in 25 (15.5%), 26 (16.1%), and 22 (13.7%) patients, respectively. Conservatively treated patients had Rutherford class ≥ IIb ischemia and embolic occlusion in 33% and 68% of cases, respectively. Their median C-reactive protein level at admission was 7 mg/L (interquartile range 2 - 31 mg/L). Among conservatively treated patients, anticoagulation therapy in half to full dose was given to 22 (88%) patients for six weeks or longer, and analgesics in low or moderate doses were given to twelve (48%) patients at discharge. The major amputation rate at 1 year was 8% among conservatively treated patients, and four patients with foot embolization had not undergone amputation at 1 year.

CONCLUSION

Patients selected for initial conservative therapy of ALI with anticoagulation alone may have a good outcome, even when admitted with Rutherford class IIb ischemia. A low C-reactive protein level at admission seems to be a favorable marker when choosing conservative therapy. A prospective, preferably multicenter, study with a predefined protocol in these conservatively treated patients is warranted to better define the dose and length of anticoagulation therapy.

Long-Term Outcome of Lower Extremity Bypass Surgery in Diabetic and Non-Diabetic Patients with Critical Limb-Threatening Ischaemia in Germany

AIM

To present the short- and long-term outcomes of lower extremity bypass (LEB) surgery in patients with critical limb-threatening ischaemia (CLTI), comparing diabetic (DM) and non-diabetic (non-DM) patients.

METHODS

Retrospective analysis of anonymised data from a nationwide health insurance company (AOK). Data from 22,633 patients (DM: n = 7266; non-DM: n = 15,367; men: n = 14,523; women: n = 8110; mean patient age: 72.5 years), who underwent LEB from 2010 to 2015, were analysed. The cut-off date for follow-up was December 31, 2018 (mean follow-up period: 55 months).

RESULTS

Perioperative mortality was 10.0% for DM and 8.2% for non-DM (p < 0.001). Patients with crural/pedal bypasses (n = 8558) had a significantly higher perioperative mortality (10.3%) than those with above-the-knee (n = 7246; 5.8%; p < 0.001) and below-the-knee bypasses (n = 6829; 8.9%; p = 0.003). The 9-year survival rates in DM patients were significantly worse, at 21.5%, compared to non-DM, at 31.1% (p < 0.001). This applied to both PAD stage III (DM: 34.4%; non-DM: 45.7%; p < 0.001) and PAD stage IV (DM: 18.5%; non-DM: 25.0%; p < 0.001). Patients with crural/pedal bypasses had a significantly inferior survival rate (25.5%) compared to those with below-the-knee (27.7%; p < 0.001) and above-the-knee bypasses (31.7%; p < 0.001).

CONCLUSION

Perioperative and long-term outcomes regarding survival and major amputation rate for CLTI patients undergoing LEB are consistently worse for DM patients compared to non-DM patients.

Lower Extremity Amputation and Peripheral Revascularisation Rates in Romania and Their Relationship with Comorbidities and Vascular Care

(1) Background: This retrospective Romanian study aimed to calculate the rate of, and comparison between, amputation and revascularisation for patients with either cardiovascular or diabetic comorbidities. (2) Materials: In our hospital-based database, we analysed patient-level data from a series of 61 hospitals for 2019, which covers 44.9% of the amputation patients for that year. The national database is compiled by the national houses of insurance and was used to follow amputations and revascularisations between 2016 and 2021. (3) Results: During the six-year period, the mean number of amputations and revascularisations was 72.4 per 100,000 inhabitants per year for both groups. In this period, a decline in open-surgical revascularisation was observed from 58.3% to 47.5% in all interventions but was not statistically significant (r = -0.20, p = 0.70). The mean age of patients with amputation (hospital-based database) was 67 years. Of these patients, only 5.1% underwent revascularisation in the same hospital prior to amputation. The most common comorbidities in those undergoing amputations were peripheral arterial disease (76.8%), diabetes (60.8%), and arterial hypertension (53.5%). Most amputations were undertaken by general surgeons (73.0%) and only a small number of patients were treated by vascular surgeons (17.4%). (4) Conclusions: The signal from our data indicates that Romanian patients probably have a high risk of amputation > 5 years earlier than Western European countries, such as Denmark, Finland, and Germany. The prevalence of revascularisations in Romania is 64% lower than in the Western European countries.

The Indirect Impact of COVID-19 Pandemic on Lower Extremity Amputations - An Australian Study

Background

The COVID-19 pandemic has had indirect and deleterious effects on patient health due to interruptions to routine provision of healthcare. This is particularly true for patients with chronic conditions like peripheral vascular disease (PVD). This study aims to evaluate the impact of the pandemic on patients with PVD in Australia by analysing rates of amputation, indications for amputation and urgency of surgery in the pre-pandemic and pandemic periods.

Methods

The Australian Vascular Audit was used to capture lower extremity amputation data in Victoria, Australia, in the 22 months before and after the start of the pandemic.

Results

The number of total amputations increased from 1770 pre-pandemic to 1850 during the pandemic, a 4.3% increase. This was largely driven by a statistically significant, 19% increase in major amputations. The number of minor amputations remained relatively similar in the two time periods. Amputations due to tissue loss secondary to arterial insufficiency increased from 474 to 526, an 11% increase, potentially indicating disruptions to revascularisation procedures contributing to the rise in amputations. Elective and emergency surgeries fell by 14% and 18%, respectively, while semi-urgent amputations increased by 32%.

Conclusion

This study found an increase in the number of amputations overall and a significant increase in major amputations during the pandemic compared to pre-pandemic times. Tissue loss secondary to arterial insufficiency was an increasingly common indication for amputation that was observed in the pandemic group, indicating that disruption to revascularisation likely contributed to this increase in amputations. These findings can inform and direct future vascular surgery service delivery to prepare for the post-pandemic recovery. Additionally, this study further confirms that patients with chronic diseases are often disproportionately disadvantaged when global crises affect routine provision of healthcare and calls for better systems to be developed that can be used in such crises in the future.

Evaluation of three nutritional indices as predictors of 2-year mortality and major amputation in patients with chronic limb-threatening ischemia

OBJECTIVE

The present study aimed to examine which nutritional index, such as the controlling nutritional status (CONUT), prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI), is better for predicting prognosis in patients with chronic limb-threatening ischemia (CLTI) following revascularization.

METHOD

We retrospectively analyzed data of patients who underwent revascularization for CLTI between 2008 and 2020. The endpoints were 2-year overall survival and limb salvage. The optimal cutoff values of 2-year overall survival and major amputation were determined by receiver operating characteristic curve analyses.

RESULT

A total of 238 patients with CLTI and 289 limbs were analyzed. The 2-year overall survival rates were 48.9%, 54.6%, and 53.5% in patients with CONUT score ≥4, PNI score <42.6, and GNRI <98.4 compared with 80.0%, 80.0%, and 78.4% in patients with CONUT score <4, PNI score ≥42.6, and GNRI ≥98.4 (p < 0.01). Age, non-ambulatory status, hemodialysis, and nutritional indices were independent risk factors for 2-year mortality in the multivariate analyses. The 2-year limb salvage rates were 70.1%, 82.2%, and 81.9% in patients with CONUT score ≥7, PNI score <41.9, and GNRI <95.3 compared with 92.8%, 98.3%, and 94.2% in patients with CONUT score <7, PNI score ≥41.9, and GNRI ≥95.3 (p < 0.01). Wound, ischemia, and foot infection stage and each nutritional index (CONUT and PNI) were independent risk factors for major amputation in multivariate analyses. The overall survival and limb salvage rates of patients with malnutrition diagnosed by CONUT score were poor compared with those of normal nutrition or malnutrition diagnosed by PNI and/or GNRI scores.

CONCLUSION

The CONUT, PNI, and GNRI scores can predict the 2-year overall survival in patients with CLTI after revascularization. The CONUT and PNI scores were associated with major amputation.

Predictive Factors for Mortality Following Major Lower Extremity Amputation

BACKGROUND

Despite advances in techniques and care, major amputation bears a high risk for mortality. Previously identified factors associated with increased risk of mortality include amputation level, renal function, and pre-operative white cell count.

METHODS

A single center retrospective chart review was conducted identifying patients who had undergone a major amputation. Chi-squared, t-testing, and Cox proportional hazard modeling were performed examining death at 6 months and 12 months.

RESULTS

Factors associated with an increased risk of six-month mortality include age (OR 1.01-1.05, P < .001), sex (OR 1.08-3.24, P < .01), minority race (OR 1.18-18.19, P < .01), chronic kidney disease (OR 1.40-6.06, P < .001), and use of pressors at the induction of anesthesia for index amputation (OR 2.09-7.85, P < .000). Factors associated with increased risk of 12 month mortality were similar.

DISCUSSION

Patients undergoing major amputation continue to suffer high mortality. Those patients who received their amputation under physiologically stressful conditions were more likely to die within 6 months. Reliably predicting six-month mortality can assist surgeons and patients in making appropriate care decisions.

Clinical Outcomes of Additional Below-The-Ankle Intervention Compared to Below-The-Knee Intervention Alone: A Post-Hoc Analysis of a Prospective Multicenter Study

PURPOSE

To investigate the clinical implication of additional below-the-ankle (BTA) intervention in patients with chronic limb-threatening ischemia (CLTI) undergoing below-the-knee (BTK) intervention.

MATERIALS AND METHODS

A sub-analysis was performed using data from the LIBERTY trial (ClinicalTrials.gov identifier NCT01855412), a prospective, observational, core-laboratory adjudicated, multicenter study of endovascular intervention in 1204 patients. Patients with CLTI (Rutherford Classification 4-6) who underwent BTK intervention were included in this sub-analysis. Participants were then stratified into 2 treatment groups according to whether at least one lesion intervened on was BTA (n=66) or not (n=273). The decision on whether and where to intervene was made during the procedure. The main outcome measures included major amputation, target vessel revascularization (TVR), major adverse events (MAE), survival, amputation-free survival, major adverse limb events or peri-operative death (MALE-POD), and all-cause death. Other outcome measures included procedural success, procedural complications, and wound healing rate.

RESULTS

There were no differences in procedural success or severe angiographic complications between the 2 groups. At 1-year post-procedure, patients in the BTK group had a higher rate of freedom from major amputation (95.0% vs. 86.9%, respectively; HR: 2.87, 95% CI: 1.17-7.03), a higher rate of freedom from TVR (80.1% vs. 66.9%, respectively; HR: 1.94, 95% CI: 1.14-3.32), a higher rate of freedom from MALE-POD (94.6% vs. 86.9%, respectively; HR: 2.65, 95% CI: 1.10-6.41), and a higher rate of freedom from MAE at both 1 (76.0% vs. 60.1%, respectively; HR: 2.00, 95% CI: 1.24-3.22) and 3 years post procedure (67.5% vs. 55.8%, respectively; HR: 1.69, 95% CI: 1.08-2.65). There was a significantly lower rate of survival in the BTK group at 3 years (74.3% vs. 91.1%, respectively; HR: 0.35, 95% CI: 0.14-0.87). After risk adjustment, there was a higher rate of all-cause death in the BTK group at 3 years (19.4% vs. 9.1%, respectively; p=0.023) post-intervention.

CONCLUSION

Patients with disease requiring intervention to BTA lesions have a potential increased amputation rate in the short term, but BTA intervention carries a potential survival benefit in the long term when compared to BTK intervention alone.

Impact of Optimal Medical Therapy on Reintervention and Survival Rates after Endovascular Infrapopliteal Revascularization

Within this single-center cohort study, we investigated the impact of optimal medical therapy on all-cause mortality, major amputation-free survival and clinically driven target lesion revascularization (CD TLR) in 552 patients with peripheral arterial disease (PAD) undergoing endovascular infrapopliteal revascularization. From the overall cohort, 145 patients were treated for intermittent claudication (IC) and 407 were treated for critical limb ischemia (CLI). Optimal medical therapy (OMT) was defined as the presence of at least one antiplatelet agent, statin and ACE inhibitor or AT-2 antagonist based on guideline recommendations. About half (55.5%) of all patients were prescribed OMT at discharge, with a higher proportion in claudicants (62.1%) versus CLI patients (53.2%). Over three years of follow-up, survival was significantly better in patients with IC (80.6 ± 3.8% vs. 59.9 ± 2.9%; p < 0.001). There was a signal towards better survival in those patients receiving OMT (log-rank p = 0.09). Similarly, amputation-free survival (AFS) was significantly better in patients with IC (p = 0.004) and also in patients receiving OMT (78.8 ± 3.6%) compared to that in those without OMT (71.5 ± 4.2%; p = 0.046). Freedom from CD TLR within three years was significantly better in the IC group (p = 0.002), but there were no statistically significant differences for CD TLR dependent on the presence of OMT (p = 0.79). In conclusion, there is still an important underuse of OMT in patients undergoing infrapopliteal interventions, which is even more pronounced in CLI despite a signal for its benefit regarding all-cause mortality and major amputation-free survival.

Revascularization prevents amputation among patients with diabetic foot during the COVID-19 era

OBJECTIVE

The COVID-19 pandemic has led to significant changes in healthcare systems that impact the management of chronic diseases such as diabetic foot (DF). We hypothesized that lack of access to healthcare would increase the severity of disease and lead to worse outcomes.

METHODS

The medical records of patients with DF were reviewed to determine demographic data and outcomes including wound healing, major amputation (MA), and death. Groups were divided into the pre-COVID-19 era (15 March 2019-15 March 2020) and the COVID-19 era (16 March 2020-16 March 2021); multivariable logistic analysis was performed to identify risk factors for MA.

RESULTS

261 patients with DF were included, 163 in the pre-COVID-19 era and 98 during the COVID-19 era. Patients in the COVID-19 presented with increased cardiovascular disease (19 vs 7%, p = 0.01), increased mean HbA1C (9.1 ± 2.1 vs 8.2 ± 2.1, p = 0.008) and higher WIFI-IV stage (78 vs 53%, p ≤ 0.0001). Patients with DF in the COVID-19 era were more likely to require MA (41 vs 21%, p ≤ 0.0001). Revascularization (OR = 0.12; 95% CI, 0.038-0.38) was a protective factor to reduce MA.

CONCLUSIONS

MA among DF patients increased two-fold during the COVID-19 era. Revascularization avoids MA in diabetic patients even during the COVID-19 pandemic, suggesting that revascularization should be performed when possible.

Treatment Outcomes between Bypass Surgery and Endovascular Therapy in Patients with Chronic Limb-Threatening Ischemia classified as Bypass-preferred category based on Global Vascular Guidelines

OBJECTIVE

To examine outcomes between bypass surgery and endovascular therapy (EVT) in patients with chronic limb-threatening ischemia (CLTI), classified as bypass-preferred according to the Global Vascular Guidelines (GVG).

METHODS

We retrospectively analyzed the multi-center data of patients who underwent infrainguinal revascularization for CLTI with Wound, Ischemia, and foot Infection (WIfI) Stage 3-4 and Global Limb Anatomical Staging System (GLASS) Stage III, which is classified as bypass-preferred category by the GVG between 2015 and 2020. The endpoints were limb salvage and wound healing.

RESULTS

We analyzed 301 patients and 339 limbs following 156 bypass surgery and 183 EVT. The 2-year limb salvage rates were 92.2% in the bypass surgery group and 76.3% in the EVT group, respectively (P < .01). The 1-year wound healing rates were 86.7% in the bypass surgery group and 67.8% in the EVT group (P < .01). Multivariate analysis shows decreased serum albumin level (P < .01), increased wound grade (P = .04), and EVT (P < .01) were risk factors for major amputation. Decreased serum albumin level (P < .01), increased wound grade (P < .01), GLASS infrapopliteal grade (P = .02), and inframalleolar (IM) P grade (P = .01), and EVT (P < .01) were risk factors for impaired wound healing. Subgroup analysis of limb salvage in patients after EVT, decreased serum albumin level (P < .01), increased wound grade (P = .03), increased IM P grade (P = .04), congestive heart failure (P < .01) were risk factors for major amputation. According to scoring by existence of these risk factors, 2-year limb salvage rates following EVT were 83.0% and 42.8% for the total score of 0-2 and of 3-4, respectively (P < .01).

CONCLUSIONS

Bypass surgery provides better limb salvage and wound healing in patients with WIfI Stage 3-4 and GLASS Stage III, which is classified as bypass-preferred category by the GVG. In patients after EVT, serum albumin level, wound grade, IM P grade, and congestive heart failure were related to major amputation. Although bypass surgery may be considered as initial revascularization procedure in patients classified as bypass-preferred category, in case that EVT has to be selected, relatively acceptable outcomes can be expected in patients with less these risk factors.

Demographics and Etiology for Lower Extremity Amputations-Experiences of an University Orthopaedic Center in Germany

Background and Objectives: Currently, the worldwide incidence of major amputations in the general population is decreasing whereas the incidence of minor amputations is increasing. The purpose of our study was to analyze whether this trend is reflected among orthopaedic patients treated with lower extremity amputation in our orthopaedic university institution. Materials and Methods: We conducted a single-center retrospective study and included patients referred to our orthopaedic department for lower extremity amputation (LEA) between January 2007 and December 2019. Acquired data were the year of amputation, age, sex, level of amputation and cause of amputation. T test and Chi² test were performed to compare age and amputation rates between males and females; significance was defined as p < 0.05. Linear regression and multivariate logistic regression models were used to test time trends and to calculate probabilities for LEA. Results: A total of 114 amputations of the lower extremity were performed, of which 60.5% were major amputations. The number of major amputations increased over time with a rate of 0.6 amputation/year. Men were significantly more often affected by LEA than women. Age of LEA for men was significantly below the age of LEA for women (men: 54.8 ± 2.8 years, women: 64.9 ± 3.2 years, p = 0.021). Main causes leading to LEA were tumors (28.9%) and implant-associated complications (25.4%). Implant-associated complications and age raised the probability for major amputation, whereas malformation, angiopathies and infections were more likely to cause a minor amputation. Conclusions: Among patients in our orthopaedic institution, etiology of amputations of the lower extremity is multifactorial and differs from other surgical specialties. The number of major amputations has increased continuously over the past years. Age and sex, as well as diagnosis, influence the type and level of amputation.

Clinical features and outcomes of diabetic foot in Argentina: a longitudinal multicenter study

INTRODUCTION

The diabetic foot (DF) is a complication with high rate of morbi-mortality. There are no data about amputation rates and mortality in Argentina related to this disease. The aim of this study was to describe clinical features of adult patients with diabetes that consulted for a foot ulcer in a 3 months' period and to evaluate outcomes six months later.

METHODS

This is a multicenter longitudinal study with six months follow up.

RESULTS

Three hundred and twelve patients from 15 health centers in Argentina were analyzed. During the follow up, the rate of major amputation was 8.33% (IC95; 5.5-11.9) (n = 26) and minor amputation 29.17% (IC95%; 24.2-34.6) (n = 91). After six months, the mortality rate was 4.49% (IC95%; 2.5-7.4) (n = 14), and 24.3% (IC95%; 19.6-29.5) remained with open wounds (n = 76) while 58.0% (IC95%; 52.3-66.5) (n = 181) healed and 7.37% became lost to follow up (n = 23). From those who required a major amputation during the study (n = 24), 5 patients died (20.8%) and in patients without amputation, 3% died (p = 0.001). Major amputation was related to age, ankle brachial index (ABI), Saint Elian score (SEWSS), SINBAD, WIfI classification, ischemia and some aspects of the wound.

DISCUSSION

Knowledge about local data will enable better decisions on health policies related to prevention and treatment of diabetic foot patients.

An index to prevent major limb amputations in diabetic foot

Objective. Besides the early detection and treatment of diabetic foot ulcers, being aware of the risk factors for major amputation plays a crucial role in preventing the major lower limb amputations. Major lower limb amputations are not just mentally and physically hard for patients, but also have an effect on patient's survival and are a financial burden on both patients and healthcare systems. Subjects and Methods. We defined 37 potential risk factors for major amputation and these risk factors were investigated among 507 patients who had ulcers in their feet and were seen by the diabetic foot ulcer council at Ege University Faculty of Medicine. In our study, 106 (20.9%) patients ended up undergoing major lower limb amputation. Results. The univariate analysis showed that 24 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, 6 risk factors remained statistically significant. Multivariate-adjusted hazard ratios were 4.172 for hyperlipidemia, 3.747 for albumin <3.365 g/dL, 3.368 for C-reactive protein (CRP) >2.185 mg/L, 2.067 for presence of gangrenous Wagner stage, 1.931 for smoking tobacco >30 pack/year, and 1.790 for hematocrit (HCT) <31.5%. Most patients with major amputation presented with a neuroischemic foot (58%). Gender and age were not found to be risk factors for major amputation. Having less than 7% of hemoglobin A1c (HbA1c) levels had a direct proportion with major amputation numbers. The mortality rates in one year, two and three years after the major amputation operations were 24.6%, 30%, and 35.9%, respectively. Conclusion. Being familiar with these risk factors for major amputation is crucial for multi-disciplinary teams to take good care of patients with diabetic foot ulcers and to lower the need for major amputations.

Incisional negative pressure wound therapy to reduce surgical-site infections in major limb amputations: a meta-analysis

Purpose

Incisional negative pressure wound therapy (iNPWT) has shown effectiveness in the treatment of high-risk surgical wounds. Especially patients with diabetes-induced peripheral arterial disease undergoing major limb amputation have a high intrinsic risk for post-surgical wound infections. While normal gauze wound dressings do not cause stimulation of microvasculature, iNPWT might improve wound healing and reduce wound complications. The purpose of this study was to systematically review the literature for rates of wound complications and readmissions, as well as post-surgical 30-day mortality.

Methods

We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score >60, non-traumatic major limb amputation, and adult patients. Traumatic amputations and animal studies were excluded. Relevant articles were reviewed independently by referring to the title and abstract. In a meta-analysis, we compared 3 studies and 457 patients.

Results

A significantly overall lower rate of postoperative complications is associated with usage of iNPWT (odds ratio (OR) = 0.52; 95% CI: 0.30-0.89; P = 0.02). There was no significant improvement for 30-day mortality, when iNPWT was used (OR= 081; 95% CI: 0.46 - 1.45; P = 0.48). Nevertheless, we did not note a significant difference in the readmission rate or revision surgery between the two groups.

Conclusion

Overall, the usage of iNPWT may reduce the risk of postoperative wound complications in major lower limb amputations but does not improve 30-day mortality rates significantly. However, to anticipate surgical-site infection, iNPWT has shown effectiveness and thus should be used whenever applicable.

Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes

BACKGROUND

Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited.

METHODS

In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed.

RESULTS

Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors.

CONCLUSION

In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017

Purpose

The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland.

Patients and Methods

This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed.

Results

During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for ≤64 years, 34.3 for 65-74 years, 81.5 for 75-84 years, 216 for ≥85 years). A decrease in incidence was detected in the <65 year-age-group (incidence 4.98 in 2007 and 1.88 in 2017; p = 0.0018). Among older age groups, there was no significant change. Half (50.6%) of all amputees were diabetics. Altogether, 472 patients (53.0%) had a history of revascularization before LEA. 80.1% of index amputations were transfemoral and 19.9% transtibial. Re-surgery was performed on 94 (10.5%) patients. The 1-, 3- and 5-year overall survival were 56%, 30%, and 18%, respectively.

Conclusion

Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.

Eligibility of Patients with Chronic Limb Threatening Ischemia for Deep Venous Arterialization

OBJECTIVES

Percutaneous deep venous arterialization (pDVA) has emerged as a new modality for limb salvage in patients with chronic limb threatening ischemia (CLTI) and no standard option for revascularization. The proportion of patients facing major amputation that are eligible for this technology remains unknown. This study aims to provide a real-life estimate of patient eligibility for pDVA to reduce major amputations.

METHODS

Electronic medical records of 100 consecutive patients with peripheral arterial disease (PAD) who underwent major amputation of 106 limbs were reviewed. Angiograms performed ≤6 months before amputation were assessed by two vascular surgeons. Disease severity was categorized using the Global Limb Anatomic Staging System and patients were classified as ideal, possible, or not candidates for pDVA. Ideal candidates had ≥1 patent tibial artery, no target in the foot, and no proximal disease. Possible candidates had ≥1 patent tibial artery with PAD, no target in the foot, and proximal disease amenable to endovascular therapy. Patients were not eligible if there was no patent tibial artery, extensive PAD, or an arterial target in the foot for bypass.

RESULTS

Of 106 limbs reviewed, 35 (33%) did not undergo angiography ≤6 months before amputation because of infection (n=14), advanced tissue loss (n=10), failed revascularizations (n=8), advanced limb ischemia (n=2), and refusing revascularization (n=1). Thus, 69 lower extremity angiograms (2 incomplete excluded) in 68 patients were analyzed. 15 patients with 16 limbs (23.2%) were identified as candidates for pDVA (ideal=7, possible=9). There were no differences in demographics between the two groups, but candidates for pDVA were less likely to have hyperlipidemia and congestive heart failure than those who were not candidates. pDVA candidates underwent significantly fewer interventions prior to major amputation compared to patients who were not candidates (1.50 ± 0.73 vs 2.61 ± 2.57, p=0.007). Angiographically, patients who were pDVA candidates had significantly higher Inframalleolar GLASS grades (1.81 ± 0.40 vs 0.86 ± 0.41, p<0.0001) but lower Femoropopliteal Glass grades (0.73 ± 1.10 vs 2.43 ± 1.71, p<0.0001) than patients who were not candidates. There was no significant difference in GLASS stage between these two groups (p=0.368). After mean follow-up of 48 months, there was no difference in mortality between both groups (40% vs 32.1%, p=0.567).

CONCLUSION

Among patients considered for revascularization, 23.2% had favorable angiography and 14.7% could have benefited for pDVA as a new therapeutic modality for limb salvage. 33% of major amputations were performed for clinically-deemed unsalvageable CLTI.

Therapeutic Alternatives in Diabetic Foot Patients without an Option for Revascularization: A Narrative Review

Background: The healing of foot wounds in patients with diabetes mellitus is frequently complicated by critical limb threatening ischemia (neuro-ischemic diabetic foot syndrome, DFS). In this situation, imminent arterial revascularization is imperative in order to avoid amputation. However, in many patients this is no longer possible (“too late”, “too sick”, “no technical option”). Besides conservative treatment or major amputation, many alternative methods supposed to decrease pain, promote wound healing, and avoid amputations are employed. We performed a narrative review in order to stress their efficiency and evidence. Methods: The literature research for the 2014 revision of the German evidenced-based S3-PAD-guidelines was extended to 2020. Results: If revascularization is impossible, there is not enough evidence for gene- and stem-cell therapy, hyperbaric oxygen, sympathectomy, spinal cord stimulation, prostanoids etc. to be able to recommend them. Risk factor management is recommended for all CLTI patients. With appropriate wound care and strict offloading, conservative treatment may be an effective alternative. Timely amputation can accelerate mobilization and improve the quality of life. Conclusions: Alternative treatments said to decrease the amputation rate by improving arterial perfusion and wound healing in case revascularization is impossible and lack both efficiency and evidence. Conservative therapy can yield acceptable results, but early amputation may be a beneficial alternative. Patients unfit for revascularization or major amputation should receive palliative wound care and pain therapy. New treatment strategies for no-option CLTI are urgently needed.

The impact of an angiosome-targeted revascularization on healing rate, limb salvage and survival in critical limb threatening ischemia

OBJECTIVE

According to the angiosome concept ulcer healing and limb salvage should be superior if direct arterial flow to the source vessel of an affected angiosome is established compared to indirect flow where the angiosome is perfused by means of collaterals. The objective of this study was to evaluate the impact of direct versus indirect revascularization (DR/IR) in endovascular versus bypass surgery on ulcer healing, limb salvage and mortality.

MATERIALS AND METHODS

A retrospective analysis of both endovascular and bypass distal (below the knee) lower limb revascularizations for chronic limb-threatening ischemia (CLTI) between 1993 and 2014 was performed.

RESULTS

The study population consisted of 126 endovascular and 198 bypass procedures. DR and IR were achieved in 57.4% and 42.6% limbs respectively. DR was not superior to IR regarding all three major endpoints when endovascular and bypass procedures were analyzed separately. Endovascular and bypass procedures resulted in comparable healing rates. All patients who did not achieve wound healing (HR 7.49; 95% CI 4.25-13.20, p = .0001) or needed to be treated with a bypass (HR 1.79; 95% CI 1.05-3.05, p = .034) were at an increased risk for major amputation. Increased mortality rate was noted after endovascular procedures (HR 1.45; 95% CI 1.04-2.00, p = .026).

CONCLUSION

This retrospective study with comparable results for DR and IR did not support the angiosome concept. Achieving wound healing remains critical in patients with CLTI to reduce major amputation rates. Overall the implications of the angiosome concept seem to be limited due to its feasibility in patients with CLTI.

Association of continuous glucose monitoring-derived time in range with major amputation risk in diabetic foot osteomyelitis patients undergoing amputation

OBJECTIVE

The metrics generated from continuous glucose monitoring (CGM), such as time in range (TIR), are strongly correlated with diabetes complications. This study explored the association of perioperative CGM-derived metrics with major amputation risk in patients with diabetic foot osteomyelitis (DFO).

METHODS

This study recruited 55 DFO patients with grade 3-4 wounds according to the Wagner Diabetic Foot Ulcer Classification System, all of whom underwent CGM for 5 days during the perioperative period. The CGM-derived metrics were defined in accordance with the most recent international consensus recommendations.

RESULTS

Patients with major amputation had significantly less TIR and higher time below range (TBR) (all p < 0.05). In binary logistic regression analyses, a lower TIR was associated with the risk of major amputation (odds ratio: 0.83 (95% confidence interval: 0.71-0.99), p = 0.039). This association remained statistically significant after adjustments for age, sex, body mass index, type of diabetes, smoking, drinking, durations of diabetes and DFU, ankle-brachial index, albumin, estimated-glomerular filtration rate, Society for Vascular Surgery wound, ischemia, and foot infection (WIfi) stage, multidrug-resistant organisms, and hemoglobin A1c. Further adjustment for the mean amplitude of glycemic excursion (MAGE) reduced this association. TBR was also independently associated with the risk of major amputation (odds ratio: 1.60 (95% confidence interval: 1.17-2.18), p = 0.003); this association persisted after adjustment for MAGE.

CONCLUSION

Perioperative TIR (3.9-10.0 mmol/L) and TBR (<3.9 mmol/L) were significantly associated with major amputation in hospitalized patients with DFO.

Outcomes in patients with chronic leg wounds in Denmark: A nationwide register-based cohort study

This study aimed to investigate incidence and predictors of wound healing, relapse, major amputation, and/or death among patients with chronic leg wounds who were referred to specialist treatment at hospital for their condition. A nationwide register-based cohort study design was applied with 5 years of follow-up. All patients with diagnoses of chronic leg wounds in Denmark between 2007 and 2012 were included (n = 8394). Clinical, social, and demographic individual-level linked data from several Danish national registries were retrieved. Incidence rate per 1000 person-years (PY) was calculated. Predictors were investigated using Cox proportional hazards regression analysis. Incidence rates of having a healed wound was 236 per 1000 PY. For relapse, the incidence rate was 75 per 1000 PY, for amputation 16 per 1000 PY, and for death 100 per 1000 PY. Diabetes, peripheral arteria disease, or other comorbidities were associated with decreased chance of wound healing and increased risk of relapse, major amputation, and death. Regional differences in all four outcomes were detected. Basic or vocational education independently predicted risk of amputation and death. This study provides epidemiological data that may help identify patients at particular risk of poor outcomes. It also elucidates social inequality in outcomes.

Scoring Model to Predict Major Amputation in Patients With Chronic Limb-Threatening Ischemia at Wound, Ischemia, and Foot Infection Clinical Stage 4 After Endovascular Therapy

PURPOSE

We investigated the predictors of major amputation (MA) at 1 year and prepared a scoring model to stratify the clinical outcomes of chronic limb-threatening ischemia (CLTI) patients at wound, ischemia, and foot infection (WIfI) clinical stage 4 after endovascular therapy (EVT).

MATERIALS AND METHODS

This study was a retrospective, observational study performed at a single center. A total of 353 CLTI patients (390 limbs) were treated with EVT between April 2007 and December 2016. Among these, limbs at WIfI clinical stages 1, 2, and 3 were excluded, and 194 limbs at WIfI clinical stage 4 (49.7%) were enrolled. The primary endpoint was major amputation (MA) free rate at 1 year. Predictors of MA at 1 year was evaluated by Cox proportional hazard analysis.

RESULTS

At 1 year, the incidence of MA was 18.0% (35 limbs). Cox proportional hazard analysis revealed that hemodialysis (hazard ratio [HR] 2.63; 95% confidence interval [CI], 1.24-5.58; p=0.012), fI3 (HR 2.54; 95% CI, 1.28-5.06; p=0.008), toe wounds (HR 0.29; 95% CI, 0.094-0.88; p=0.029), and visible blood flow to the wound (HR 0.43; 95% CI, 0.21-0.89; p=0.023) were associated with MA. We assigned 1 point for positive predictors of MA, hemodialysis, and fI3; 1 point was deducted for negative predictors of MA, toe wounds, and visible blood flow to the wound. A score of -2 or -1, was defined as the low-risk group, 0 was defined as the intermediate-risk group, and +1 or +2 were defined as the high-risk group. At 1 year, MA free rate, wound healing rate, and amputation-free survival rate were stratified according to a scoring model. MA free rate was 96.6% in low-risk, 72.4% in intermediate-risk, and 67.3% in high-risk (p<0.001); wound healing rate was 67.8% in low-risk, 27.6% in intermediate-risk, and 4.1% in high-risk (p<0.001); amputation-free survival rate was 65.3% in low-risk, 44.8% in intermediate-risk, and 18.4% in high-risk (p<0.001).

CONCLUSIONS

The scoring model based on the predictors of MA stratified clinical outcomes in CLTI patients at WIfI clinical stage 4.

Cohort Study Examining the Association of Immunosuppressant Drug Prescription With Major Adverse Cardiovascular and Limb Events in Patients With Peripheral Artery Disease

AIM

Immune activation is strongly implicated in atherosclerotic plaque instability, however, the effect of immunosuppressant drugs on cardiovascular events in patients with peripheral artery disease (PAD) is not known. The aim of this study was to assess whether prescription of one or more immune suppressant drugs was associated with a lower risk of major adverse cardiovascular (MACE; i.e. myocardial infarction, stroke or cardiovascular events) or limb events (MALE; i.e. major amputation or requirement for peripheral revascularization) in patients with PAD.

METHODS

A total of 1506 participants with intermittent claudication (n = 872) or chronic limb threatening ischemia (CLTI; n = 634) of whom 53 (3.5%) were prescribed one or more immunosuppressant drugs (prednisolone 41; methotrexate 17; leflunomide 5; hydroxychloroquine 3; azathioprine 2; tocilizumab 2; mycophenolate 1; sulfasalazine 1; adalimumab 1) were recruited from 3 Australian hospitals. Participants were followed for a median of 3.9 (inter-quartile range 1.2, 7.3) years. The association of immunosuppressant drug prescription with MACE or MALE was examined using Cox proportional hazard analyses.

RESULTS

After adjusting for other risk factors, prescription of an immunosuppressant drug was associated with a significantly greater risk of MACE (Hazard ratio, HR, 1.83, 95% confidence intervals, CI, 1.11, 3.01; P = 0.017) but not MALE (HR 1.32, 95% CI 0.90, 1.92; P = 0.153). In a sub-analysis restricted to participants with CLTI findings were similar: MACE (HR 2.44, 95% CI 1.32, 4.51; P = 0.005); MALE (HR 1.38, 95% CI 0.87, 2.19; P = 0.175); major amputation (HR 1.37, 95% CI 0.49, 3.86; P = 0.547).

CONCLUSIONS

This cohort study suggested that immunosuppressant drug therapy is associated with a greater risk of MACE amongst patients with PAD.

Major Lower Limb Amputations: Recognizing Pitfalls

Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.

Percutaneous Saphenous Vein Arterialization

PURPOSE

In patients with no-option critical limb-threatening ischemia, venous foot arterialization can be considered the last chance before major amputation. Up until now, a really significant limitation of endovascular arterialization compared with surgery was the possibility to obtain arterial flow into the foot only through the deep plantar network.

TECHNIQUE

Two 5-mm snares are placed: one in the proximal tibial artery and the other in the great saphenous vein. After passing through these snares with a needle and a guidewire and closing the snares, the guidewire is pulled through the proximal arterial sheath and the distal venous sheath. Thus, the arterial-venous connection is created. A covered stent is, then, placed between the artery and the vein to avoid leakage.

CONCLUSIONS

Based on our knowledge, this is the first described totally percutaneous arterialization of the superficial dorsal venous foot system, through reverse flow in the great saphenous vein.

Autologous Peripheral Blood Mononuclear Cells for Limb Salvage in Diabetic Foot Patients with No-Option Critical Limb Ischemia

Peripheral blood mononuclear cells (PBMNCs) are reported to prevent major amputation and healing in no-option critical limb ischemia (NO-CLI). The aim of this study is to evaluate PBMNC treatment in comparison to standard treatment in NO-CLI patients with diabetic foot ulcers (DFUs). The study included 76 NO-CLI patients admitted to our centers because of CLI with DFUs. All patients were treated with the same standard care (control group), but 38 patients were also treated with autologous PBMNC implants. Major amputations, overall mortality, and number of healed patients were evaluated as the primary endpoint. Only 4 out 38 amputations (10.5%) were observed in the PBMNC group, while 15 out of 38 amputations (39.5%) were recorded in the control group (p = 0.0037). The Kaplan-Meier curves and the log-rank test results showed a significantly lower amputation rate in the PBMNCs group vs. the control group (p = 0.000). At two years follow-up, nearly 80% of the PBMNCs group was still alive vs. only 20% of the control group (p = 0.000). In the PBMNC group, 33 patients healed (86.6%) while only one patient healed in the control group (p = 0.000). PBMNCs showed a positive clinical outcome at two years follow-up in patients with DFUs and NO-CLI, significantly reducing the amputation rate and improving survival and wound healing. According to our study results, intramuscular and peri-lesional injection of autologous PBMNCs could prevent amputations in NO-CLI diabetic patients.

The Effects of Antimicrobial Resistance and the Compatibility of Initial Antibiotic Treatment on Clinical Outcomes in Patients With Diabetic Foot Infection

We aimed to determine pathogen microorganisms, their antimicrobial resistance patterns, and the effect of initial treatment on clinical outcomes in patients with diabetic foot infection (DFI). Patients with DFI from 5 centers were included in this multicenter observational prospective study between June 2018 and June 2019. Multivariate analysis was performed for the predictors of reinfection/death and major amputation. A total of 284 patients were recorded. Of whom, 193 (68%) were male and the median age was 59.9 ± 11.3 years. One hundred nineteen (41.9%) patients had amputations, as the minor (n = 83, 29.2%) or major (n = 36, 12.7%). The mortality rate was 1.7% with 4 deaths. A total of 247 microorganisms were isolated from 200 patients. The most common microorganisms were Staphylococcus aureus (n = 36, 14.6%) and Escherichia coli (n = 32, 13.0%). Methicillin resistance rates were 19.4% and 69.6% in S aureus and coagulase-negative Staphylococcus spp., respectively. Multidrug-resistant Pseudomonas aeruginosa was detected in 4 of 22 (18.2%) isolates. Extended-spectrum beta-lactamase-producing Gram-negative bacteria were detected in 20 (38.5%) isolates of E coli (14 of 32) and Klebsiella spp. (6 of 20). When the initial treatment was inappropriate, Klebsiella spp. related reinfection within 1 to 3 months was observed more frequently. Polymicrobial infection (p = .043) and vancomycin treatment (p = .007) were independent predictors of reinfection/death. Multivariate analysis revealed vascular insufficiency (p = .004), hospital readmission (p = .009), C-reactive protein > 130 mg/dL (p = .007), and receiving carbapenems (p = .005) as independent predictors of major amputation. Our results justify the importance of using appropriate narrow-spectrum empirical antimicrobials because higher rates of reinfection and major amputation were found even in the use of broad-spectrum antimicrobials.

Comparison of WIFi, University of Texas and Wagner Classification Systems as Major Amputation Predictors for Admitted Diabetic Foot Patients: A Prospective Cohort Study

Introduction:

Classifications systems are powerful tools that could reduce the length of hospital stay and economic burden. The Would, Ischemia, and Foot Infection (WIFi) classification system was created as a comprehensive system for predicting major amputation but is yet to be compared with other systems. Thus, the objective of this study is to compare the predictive abilities for major lower limb amputation of WIFi, Wagner and the University of Texas Classification Systems among diabetic foot patients admitted in a tertiary hospital through a prospective cohort design.

Materials and Methods:

Sixty-three diabetic foot patients admitted from June 15, 2019 to February 15, 2020. Methods included one-on-one interview for clinico-demographic data, physical examination to determine the classification. Patients were followed-up and outcomes were determined. Pearson Chi-square or Fisher’s Exact determined association between clinico-demographic data, the classifications, and outcomes. The receiver operating characteristic (ROC) curve determined predictive abilities of classification systems and paired analysis compared the curves. Area Under the Receiver Operating Characteristic Curve (AUC) values used to compare the prediction accuracy. Analysis was set at 95% CI.

Results:

Results showed hypertension, duration of diabetes, and ambulation status were significantly associated with major amputation. WIFi showed the highest AUC of 0.899 (p = 0.000). However, paired analysis showed AUC differences between WIFi, Wagner, and University of Texas classifications by grade were not significantly different from each other.

Conclusion:

The WIFi, Wagner, and University of Texas classification systems are good predictors of major amputation with WIFi as the most predictive.

Risk Factors for Major Amputation in Diabetic Foot Ulcer Patients

BACKGROUND

The purpose of our study was to identify the new and the more specific risk factors for major amputation in patients with diabetic foot ulcer (DFU).

METHODS

We used data from the Electronic Medical Record (EMR) database of our hospital from February 2014 to July 2020. Patients with DFU and amputation were included in the study. The logistic regression model was adjusted for demographic characteristics and related comorbidities between major and minor amputation groups.

RESULTS

Among 3654 patients with DFU, 363 (9.9%) were amputated. Patients with major versus minor amputation, in multivariable logistic regression models, major amputation independent factors included previous amputation history (odds ratio [OR] 2.31 [95% CI 1.17-4.53], p = 0.02), smoking (2.58 [1.31-5.07], p = 0.01), coronary artery disease (CAD) (2.67 [1.35-5.29], p = 0.03), ankle brachial index (ABI) <0.4 (15.77 [7.51-33.13], p < 0.01), Wagner 5 (5.50 [1.89-16.01], p < 0.01), activated partial thromboplastin time (APTT) (1.23 [1.03-1.48], p = 0.01), glycosylated hemoglobin A1c (HbA1c) (1.23 [1.03-1.48], p = 0.03), hemoglobin (Hb) (0.98 [0.96-1.00], p = 0.01), plasma albumin (ALB) (0.88 [0.81-0.95], p < 0.01) and white blood cell (WBC) (1.10 [1.04-1.16], p < 0.01).

CONCLUSION

Major amputation was associated with previous amputation history, smoking, CAD, Wagner 5, ABI <0.4, HbA1c, Hb, ALB, WBC, and APTT might be a new independent factor. In view of these factors, early prevention and guidance promptly orientated by multidisciplinary is of great significance to reduce the disability rate and economic burden.

[Atypical presentation of diabetic foot in post-COVID-19 patients]

Medical attention of patients with a diabetic foot has been disrupted since de COVID-19 pandemic began, because health systems had to provide care to those patients affected by this disease to the detriment of the control of chronic diseases. Several reports show an increase in amputations during the pandemic, primarily due to the lack of health controls in patients suffering from diabetes or diabetic foot. This could have resulted in later consultation and more severe presentations. We describe three medical cases that had recently been affected by COVID-19 and developed a rare and rapidly evolving diabetic foot that required a major amputation. One possible explanation for this atypical presentation could be that COVID-19 predisposes patients to vein and arterial thrombosis due to systemic inflammation, platelet activation, endothelial dysfunction and stasis from prolonged immobility. This could have exacerbated chronic ischemia secondary to diabetes in which metabolic disturbances often seen in these patients predispose to atherosclerosis.

Evolution of Major Amputation Risk in Patients Hospitalized in France for Critical Limb Ischemia: The COPART Registry

Over the past decade, improvements in medical treatment and revascularization techniques have been beneficial for patients with peripheral artery disease in the late stage of critical limb ischemia (CLI). We evaluated the putative reduction in the number of major amputees in the Cohorte des Patients ARTeriopathes (COPART) cohort over time. Patients were selected from this multicenter cohort, from 2006 to 2016, for CLI according to Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease II criteria. Patients included before and after 2011 were compared. Patients were followed for 1 year. Primary outcome was the rate of major amputations. Secondary outcomes were minor amputations, deaths from all causes, cardiovascular deaths; 989 patients were included, 489 before 2011 and 450 after 2011. There was a significant decrease in rates of major amputation after 2011 (17% vs 25%), confirmed in multivariate analysis (odds ratio [OR]: 1.5 [1.1-2.2]), an increase in revascularization, particularly distal angioplasty (OR: 2.7 [1.7-4.4]) and increased statin intake (OR: 1.6 [1.1-2.1]). For secondary outcomes, there was no significant difference. Limb prognosis of CLI patients has improved over the past decade, possibly due to more revascularizations, particularly distal ones, and increased statin use.

Midterm Fate of the Contralateral Foot in Charcot Arthropathy

BACKGROUND

The contralateral foot in Charcot arthropathy or neuroarthropathy (CN) is subject to increased plantar pressure. To date, the clinical consequences of this pressure elevation are yet to be determined. The aim of this study was to evaluate ulcer and amputation rates of the contralateral foot in CN.

METHODS

We abstracted the medical records of 130 consecutive subjects with unilateral CN. Rates of contralateral CN development and recurrence, contralateral ulcer development, and contralateral amputations were recorded. Statistical analysis was performed to identify possible risk factors for contralateral CN and ulcer development, and contralateral amputation. Mean follow-up was 6.2 (SD 4) years.

RESULTS

After a mean of 2.5 years, 19.2% patients developed contralateral CN. Female gender was associated with contralateral CN development (odds ratio 3.13, 95% confidence interval 1.27, 7.7). Overall, 46.2% patients developed a contralateral ulcer. Among the patients who developed contralateral CN, 60% developed an ulcer. Sanders type 2 at the index foot (midfoot CN) was significantly associated with contralateral ulcer development. Ulcer-free survival (UFS) differed significantly between patients with diabetes type 1 (median UFS 5131 days) and patients with diabetes type 2 (median UFS 2158 days). A total of 25 amputations had to be performed in 22 (16.9%) patients. Three of those 22 patients (2.3%) needed major amputation.

CONCLUSION

Almost 20% of patients developed contralateral CN. Nearly half of people with CN developed a contralateral foot ulceration. Patients with type 2 diabetes had significantly shorter UFS than patients with diabetes type 1. Every sixth patient needed an amputation, with the majority being minor amputations. The contralateral foot should be monitored closely and included in the treatment in patients with CN.

LEVEL OF EVIDENCE

Level IV, retrospective study.

A Comparison Between Diabetic Foot Classifications WIfI, Saint Elian, and Texas: Description of Wounds and Clinical Outcomes

Several wound classification systems are used to assess diabetic foot wounds. The recommendations for their use depend on the authors and foot associations. In this study, we compared Saint Elian score system, WIfI classification and Texas in 101 patients with foot wounds, and we followed them for a median of 149 days, finding differences both in the assigned risk and in the association with major amputation and wound healing. Saint Elian and WIfI scores match when Saint Elian is low or high risk but not when it is moderate. WIfI stages correlate with major amputation and wound healing. Saint Elian III correlates with major amputation. Prevalence of major amputations was 41% for WIfI 4 and 83% for Saint Elian III. WIfI 1 and 2 and Saint Elian I had a rate of wound healing of 80% to 85%. Stages 1 and 2 of WIfI score behave similar with regard to wound healing, 82% and 80% (P = .71), and major amputation, 0% and 10% (P = .68). Stages I and II of Saint Elian have the same rates of major amputation, 0% and 8% (P = .66), but not of wound healing, 85% and 51% (P < .05). The optimal cut point for detecting major amputation in Saint Elian is 18, with a sensitivity of 90.9 and specificity of 84.9, but there is no recommended cut point for wound healing. These classifications are validated for their use in diabetic foot wounds and to assess amputation risk, helping physicians make decisions and talk to the patients about prognosis.

Limb Salvage in Patients With Severe Critical Limb Ischemia (CLI) After Referral for a Second Opinion to a Dedicated CLI Center

The complexity of critical limb ischemia (CLI) requires dedicated multidisciplinary teams of different care providers, who will supervise the full cycle of CLI care. Until CLI treatment is fully centralized, such dedicated teams may work as second-opinion tools before major amputation is undertaken in CLI patients. The aim of the study is to assess the effectiveness of a well-timed referral to a dedicated CLI-center of patients scheduled to major amputation elsewhere. A retrospective analysis of all CLI-patients treated in our department between January 2019 and March 2020 was conducted. Only patients scheduled for a major amputation elsewhere and referred to our clinic were included. Primary endpoint was amputation-free survival, whereas technical success, limb salvage, minor amputation rate, re-admission at 30 days, and frequency of medication change from other disciplines were the secondary endpoints. Sixteen patients with 19 treated limbs were identified and included in this analysis. The WIfI (wound, infection and foot ischemia) clinical stage on admission was 2 in 4 limbs (21%), 3 in 5 limbs (26%), and 4 in 10 limbs (53%). All patients underwent advanced endovascular revascularization. Minor amputation was performed in 8 patients (42%). Amputation-free survival at 6 months was 93% with limb salvage rate of 100%. Technical success and re-admission rates at 30 days was 95% and 6%, respectively. There was a medication adjustment from other specialties in 13 (81%) patients. Patients in severe stages of CLI scheduled to major amputation reached high limb salvage and survival rate, since they are referred for a second opinion to a dedicated multidisciplinary CLI team.

Risk Factors for Major Amputation on Hindfoot Ulcers in Hospitalized Diabetic Patients

Objective: The purpose of this study was to investigate the risk factors for major amputation in patients hospitalized with diabetic foot ulcers involving the hindfoot. Approach: Between January 2003 and October 2017, a total of 1,657 diabetic patients were admitted to the diabetic wound center of Korea University Guro Hospital, for the management of foot ulcers. Among the admitted patients, 117 diabetic patients with hindfoot ulcers were included in this study. One hundred and four patients (89%) healed without major amputation, while 13 patients (11%) healed with major amputation. Data related to 88 potential risk factors, including demographics, ulcer condition, vascularity, bioburden, neurology, and serology, were collected from patients in these two groups for comparison. Results: Among the 88 potential risk factors, 15 showed statistically significant differences between the two groups. In univariate analysis of 88 potential risk factors, nine showed statistically significant differences. In stepwise multiple logistic regression analysis, three of the nine risk factors remained statistically significant. Multivariate-adjusted odds ratios for pulmonary disorders, erythrocyte sedimentation rate (ESR) levels, and total iron-binding capacity (TIBC) levels were 38.525, 1.047, and 0.976, respectively. Innovation: Compared with forefoot and midfoot ulcers, diabetic foot ulcers involving the hindfoot are at increased risk of major amputation because infection may spread proximal to the ankle. However, large-scale cohort studies that specifically discuss the outcomes and characteristics of diabetic hindfoot ulcers are not widely available. Conclusion: Risk factors for major amputation in patients hospitalized with diabetic hindfoot ulcers include pulmonary disorders, high levels of ESR, and decreased TIBC levels.

Risk Factors Associated With Major Lower Extremity Amputation After Osseous Diabetic Charcot Reconstruction

Patients with diabetic Charcot neuroarthropathy (CN) are at high risk for ulcerations and major lower extremity amputations (LEAs). Osseous reconstruction is an important component in ulcer healing and prevention; however, despite such efforts, major LEAs remain a serious postreconstruction concern. The aim of this study was to identify risk factors for major LEA in patients who underwent osseous Charcot reconstruction. A retrospective review was performed on 331 patients with the diagnosis of CN in the foot and ankle treated over a 16-year period. Two hundred eighty-five patients were included after exclusion of those without diabetes. Demographic data, anatomic wound location, surgical interventions, wound healing status, and the level of eventual amputation were recorded. Multivariate logistic regression and Fisher's exact test were used for analysis. All patients had diabetes, neuropathy, or CN and required osseous reconstruction. Risk factors and their respective odds ratios (ORs) are as follows: postoperative nonunion (OR 8.5, 95% confidence interval [CI] 2.2 to 33.5, 0.0023), development of new site of CN (OR 8.2; 95% CI 1.1 to 62.9; p = .0440), peripheral arterial disease (OR 4.3; 95% CI 1.7 to 11.0; p = .0020), renal disease (OR 3.7; 95% CI 1.6 to 8.8; p = .0025), postoperative delayed healing (OR 2.6; 95% CI 1.1 to 6.5; p = .0371), postoperative osteomyelitis (OR 2.4; 95% CI 1.0 to 5.9; p = .0473), or elevated glycated hemoglobin (OR 1.2; 95% CI 1.0 to 1.4; p = .0053). Independent risk factors found to be statistically significant for major LEA in diabetic CN in the setting of osseous reconstruction must be mitigated for long-term prevention of major amputations.

A meta-analysis of the relationship between foot local characteristics and major lower extremity amputation in diabetic foot patients

OBJECTIVE

To clarify and quantify risk factors among local characteristics of the foot for major amputation in diabetic foot patients.

METHODS

Articles published before January 2018 on PubMed and Embase were conducted observational studies about risk factors for major amputation in patients with diabetic foot were retrieved and systematically reviewed by using Stata 12.0 statistical software.

RESULTS

A total of 4668 major amputees and 65 831 controls were reported in 18 observational studies. Across the studies, the overall odds ratios (ORs) and 95% confidence intervals (CIs) of significant risk factors are ulcer reaching bone (OR, 11.796; 95% CI, 6.905-20.152), gangrene (OR, 6.487; 95% CI, 4.088-10.293), hindfoot position (OR, 3.913; 95% CI, 2.254-6.795), decreased ankle-brachial index (ABI) (OR, 2.522; 95% CI, 1.805-3.523), infection (OR, 2.516; 95% CI, 1.708-3.706), peripheral arterial disease (PAD) (OR, 2.114; 95% CI, 1.326-3.372). While there is no significant difference in the size of the ulcer, neuropathy, Charcot foot, osteomyelitis and intermittent claudication (OR, 1.15; 95% CI, 0.85-1.54).

CONCLUSION

Factors among local characteristics of the foot associated with major amputation in patients with diabetic foot are the ulcer reaching bone, gangrene, hindfoot position, decreased ABI, infection, and PAD, a negative risk factor for the risk of amputation. Further studies are required to provide more details of foot local characteristics.

The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation

AIMS AND OBJECTIVES

To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI).

BACKGROUND

CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning.

DESIGN

Longitudinal qualitative study using Heideggerian phenomenology.

METHODS

Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed.

RESULTS

Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity).

CONCLUSIONS

Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy.

RELEVANCE TO CLINICAL PRACTICE

A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.

Factors associated with outcome of endovascular treatment of iliac occlusive disease: a single-center experience

Background

Endovascular treatment (ET) of iliac occlusive disease (IOD) is well established in literature. Use of stents in IOD has achieved long-term limb salvage and patency rates similar to those of open surgery, with lower morbidity and mortality rates.

Objectives

To report the long-term outcomes, particularly limb salvage and patency rates, of ET for IOD and the factors associated with these outcomes.

Methods

This retrospective cohort study included patients with IOD who underwent iliac angioplasty (IA), between January 2009 and January 2015. Patients with critical limb ischemia or incapacitating claudication were included.

Results

In total, 48 IA procedures were performed in 46 patients, with an initial technical success rate of 95.83%. Failure occurred in two patients, who were excluded, leaving 44 patients and 46 IA. The primary patency, secondary patency, limb salvage, and survival rates at 1200 days were 88%, 95.3%, 86.3%, and 69.9%, respectively. Univariate and multivariate Cox regression revealed that the primary patency rate was significantly worse in patients with TASC type C/D than in patients with TASC type A/B (p = 0.044). Analysis of factors associated with major amputation using Cox regression showed that the rate of limb loss was greater in patients with TASC type C/D (p = 0.043). Male gender was associated with reduced survival (p = 0.011).

Conclusions

TASC type C/D was associated with a higher number of reinterventions and with worse limb loss and primary patency rates. Male gender was associated with a worse survival rate after ET of IOD.

The Association Between Geographic Density of Infectious Disease Physicians and Limb Preservation in Patients With Diabetic Foot Ulcers

Background

Avoiding major (above-ankle) amputation in patients with diabetic foot ulcers is best accomplished by multidisciplinary care teams with access to infectious disease specialists. However, access to infectious disease physicians is partially influenced by geography. We assessed the effect of living in a hospital referral region with a high geographic density of infectious disease physicians on major amputation for patients with diabetic foot ulcers. We studied geographic density, rather than infectious disease consultation, to capture both the direct and indirect (eg, informal consultation) effects of access to these providers on major amputation.

Methods

We used a national retrospective cohort of 56440 Medicare enrollees with incident diabetic foot ulcers. Cox proportional hazard models were used to assess the relationship between infectious disease physician density and major amputation, while controlling for patient demographics, comorbidities, and ulcer severity.

Results

Living in hospital referral regions with high geographic density of infectious disease physicians was associated with a reduced risk of major amputation after controlling for demographics, comorbidities, and ulcer severity (hazard ratio, .83; 95% confidence interval, .75–.91; P < .001). The relationship between the geographic density of infectious disease physicians and major amputation was not different based on ulcer severity and was maintained when adjusting for socioeconomic factors and modeling amputation-free survival.

Conclusions

Infectious disease physicians may play an important role in limb salvage. Future studies should explore whether improved access to infectious disease physicians results in fewer major amputations.

Acute Limb-Threatening Ischemia Associated With Antiphospholipid Syndrome: A Report of Two Cases

Acute limb ischemia results from sudden deterioration in the arterial supply to the limb, occasionally leading to limb loss or fatality. Antiphospholipid syndrome (APS) is known to induce acute limb ischemia among the various etiologies responsible for arterial obstruction. APS is a systemic autoimmune disorder characterized by a combination of arterial and/or venous thrombosis and limb loss. It is often accompanied by a mild-to-moderate thrombocytopenia and elevated titers of antiphospholipid antibodies, including the lupus anticoagulant and the anticardiolipin antibodies. In the present report, we present 2 cases of acute limb ischemia due to APS associated with systemic lupus erythematosus. Angiography revealed arterial obstruction distal to the popliteal artery in both patients, and each patient eventually underwent below-the-knee amputation. Surgeons treating acute limb ischemia should remember APS, although this disease might not be common in daily clinical practice.

Survival of diabetes patients with major amputation is comparable to malignant disease

INTRODUCTION

Almost all studies on diabetic foot syndrome focused on prevention of amputation and did not investigate long-term prognosis and survival of patients as a primary outcome parameter.

METHODS

We did a retrospective cohort study including 314 patients who had diabetic foot syndrome and underwent amputation between December 1995 and January 2001.

RESULTS

A total of 48% of patients received minor amputation (group I), 15% only major amputation (group II) and 36% initially underwent a minor amputation that was followed by a major amputation (group III). Statistically significant differences were observed in comparison of the median survival of group I to group II (51 vs. 40 months; p = 0.016) and of group II to group III (40 vs. 55 months; p = 0.003).

DISCUSSION

The prognosis of patients with major amputation due to diabetic foot syndrome is comparable to patients with malignant diseases. Vascular interventions did not improve the individual prognosis of patients.

Lower extremity amputations: factors associated with mortality or contralateral amputation

BACKGROUND

Tissue loss or gangrene in the setting of lower extremity peripheral artery disease (PAD) may result in amputation. Previous studies have demonstrated elevated mortality rates after major transtibial and transfemoral amputation. Also, amputation of 1 leg may be associated with subsequent major amputation of the contralateral leg. The aim of our study was to identify patient variables associated with mortality and contralateral amputation.

METHODS

We reviewed the medical records of patients who underwent transfemoral or transtibial amputation secondary to PAD from 2004 to 2009. A total of 454 consecutive major amputations were performed on 391 patients, with 63 of these having a subsequent contralateral amputation. Standard demographic information, comorbidities, prior vascular interventions, and relevant procedural information were extracted from patient records. Kaplan-Meier estimates of survival were calculated. Cox proportional hazard models were used to estimate the risk of death and contralateral amputation. Multivariate Cox proportional hazards models were fit for all variables shown to be marginally associated in the univariate model.

RESULTS

In 391 amputees, the mean age was 67.3 years, 63% were male and 62% were caucasian. Patients had high rates of diabetes (63%), hypertension (83%), renal insufficiency (35%), hyperlipidemia (51%), and prior ipsilateral vascular intervention (75%). Seventy percent of patients had below-knee amputations. Perioperative mortality was 9.2% (n = 36). Survival at 12 and 24 months was 70% (95% confidence interval [CI], 65%-74%) and 60% (95% CI, 55%-65%), respectively. Multivariate analysis demonstrated that several independent factors were detrimental to survival including chronic obstructive pulmonary disease (hazard ratio [HR] 1.82, P = .002), dialysis dependence (HR 2.50, P < .001), high cardiac risk (HR 2.20, P < .001), and guillotine amputation (HR 2.49, P = .004). Dialysis (HR 2.42, P = .002) and revision of the index ipsilateral amputation to a higher level (HR 2.02, P = .014) were associated with a subsequent contralateral amputation.

CONCLUSIONS

Patients with advanced PAD that require lower extremity amputation have diminished survival and significant contralateral amputation rates. Elderly patients on dialysis are particularly prone to dying or losing the other leg after a major amputation. These data support strategies to enhance limb preservation and optimize medical comorbidities in these patients.

Improving major amputation rates in the multicomplex diabetic foot patient: focus on the severity of peripheral arterial disease

OBJECTIVE

Peripheral arterial disease (PAD), as well as diabetic neuropathy, is a risk factor for the development of diabetic foot ulcers. The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic foot by stratifying these subjects according to the severity of PAD.

RESEARCH DESIGN AND METHODS

In a prospective study, patients with new diabetic foot ulcers have been treated and investigated by structured healthcare. Subjects were recruited between 1 January 2000 and 31 December 2007. All study participants underwent a 2-year follow-up observation period. The patients underwent a standardized examination and classification of their foot ulcers according to a modification of the University of Texas Wound Classification System. The severity of PAD was estimated by measurement of the ankle brachial index (ABI) and the continuous wave Doppler flow curve into undisturbed perfusion (0.9 < ABI < 1.3), compensated perfusion (0.5 < ABI < 0.9), decompensated perfusion (ABI < 0.5) and medial arterial calcification.

RESULTS

A total of 678 patients with diabetic foot were consecutively included into the study (69% male, mean age 66.3 ± 11.0 years, mean diabetes duration 15.8 ± 10.2 years). Major amputations (above the ankle) were performed in 4.7% of the patients. 22.1% of these subjects had decompensated PAD. These subjects had delayed ulcer healing, higher risk for major amputation [odds ratio (OR) 7.7, 95% confidence interval (CI) 2.8-21.2, p < 0.001] and mortality (OR 4.9, 95 % CI 1.1-22.1, p < 0.05).

CONCLUSION

This prospective study shows that the severity of PAD significantly influences the outcome of diabetic foot ulcers regarding to wound healing, major amputation and mortality.