Clinical and hemodynamic results of bypass to isolated tibial artery segments for ischemic ulceration of the foot.

Patients with ischemic ulceration of the foot and no continuous tibial or inframalleolar vessels acceptable for bypass are often treated with primary amputation. We have performed autogenous vein bypass to isolated tibial artery segments (ITAS) in nine patients with ischemic foot ulcers and no other outflow options. We reviewed the clinical and hemodynamic results of these bypasses to assess the efficacy of this approach. Hemodynamic comparisons of these ITAS bypasses were made to a concurrent series of 26 bypasses to intact tibial arteries and 24 inframalleolar artery bypasses assessed during routine follow-up. Eight of the bypasses originated from the above-knee popliteal artery and one from the profunda femoris artery. Recipient vessels were the anterior tibial (seven), peroneal (one), and posterior tibial (one) arteries. Although mean ankle brachial indices (ABI) increased significantly from 0.26 +/- 0.06 preoperatively to 0.75 +/- 0.04 postoperatively (p = 0.0015), ITAS bypass patients had lower mean postoperative ABIs than patients with bypasses to intact tibial (ABI = 0.98 +/- 0.03, p = 0.0001) or pedal arteries (ABI = 1.02 +/- 0.04, p = 0.0005). Similarly, duplex scan-derived peak systolic flow velocities of the ITAS bypasses (mean: 52.9 +/- 5.8 cm/sec) were lower than those of intact tibial artery bypasses (mean: 80.1 +/- 6.1 cm/sec, p = 0.02) but did not differ from those of pedal bypasses (mean: 59.5 +/- 3.5 cm/sec, p = 0.34). No ITAS bypass grafts have failed during a mean follow-up of 12.3 +/- 2.7 months. Although wound healing was prolonged (mean: 3.1 +/- 0.6 months), the wounds of eight of nine patients eventually healed, with three patients requiring minor amputations (one digital amputation and two transmetatarsal amputations). Although the hemodynamic results of ITAS bypass are inferior to those of more conventional bypasses, the early patency rates and successful healing of ischemic wounds confirm that it is a valid alternative in the threatened limb with no other outflow options.     

Factors influencing ulcer healing in patients with combined arterial and venous insufficiency

PURPOSE: The purpose of this study was to determine the effectiveness of treatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better define criteria for interventional therapy.Study Design: We retrospectively reviewed the records of patients treated at four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, absent pedal pulse, and at least one in-line arterial stenosis > 50% by arteriography. Venous insufficiency was defined as characteristic clinical findings and duplex findings of either reflux or thrombus in the deep or superficial system. Clinical, demographic, and hemodynamic parameters were statistically analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. RESULTS: Fifty-nine patients with CAVI were treated for nonhealing ulcers that had been present from 1 to 39 months (mean, 6.4 months). All patients had edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty-two patients underwent arterial bypass grafting, three underwent an endarterectomy, one underwent superficial femoral artery percutaneous transluminal angioplasty, and three underwent primary below-knee amputation. For purposes of analysis, patients were divided into four groups according to the pattern of arterial and venous disease and the success of arterial reconstruction. Group 1 consisted of 22 patients with a patent arterial graft, superficial venous incompetence, and normal deep veins. Group 2 consisted of seven patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosis (DVT), and group 4 included eight patients with an occluded arterial graft. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine patients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) required below-knee amputation for nonhealed ulcers and uncontrolled infection. No patient with graft occlusion was healed, and 12 ulcers persisted despite successful arterial reconstruction. Twenty-one (78%) of 27 patients undergoing greater saphenous vein stripping were healed, but none of these patients had DVT. The mean interval from bypass graft to healing was 7.9 months. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas only two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significant in predicting healing (P <.05). CONCLUSIONS: Ulcers may develop anywhere on the calf or foot in patients with CAVI, and healing requires correction of arterial insufficiency. Patients with prior DVT are unlikely to heal, even with a patent bypass graft. Ulcer healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prior DVT are unlikely to benefit from aggressive arterial or venous reconstruction.     

Multimodal therapy as an algorithm to limb salvage in diabetic patients with large heel ulcers

In many series of diabetic foot ulcer care, heel ulcers greater than 4 cm across have been identified as an independent predictor of limb loss. Therefore, we set out to pursue the most aggressive limb salvage algorithm in patients with heel ulcers greater than 4 cm in diameter. Over 5 years, we identified 21 patients, 39-84 years of age, all with diabetes mellitus, with heel ulcers greater than 4 cm in diameter and had magnetic resonance imaging or bone scan evidence of osteomyelitis. Seven of the 21 patients had end-stage renal disease defined as being haemodialysis dependent. All patients had ankle brachial indices <0·4 or monophasic pulse volume recordings. All patients underwent distal bypass surgery with vein. After adequate perfusion was obtained, all patients underwent partial calcanectomy and intra-operative negative pressure wound therapy (NPWT) placement. This was followed by treatment with recombinant platelet-derived growth factor (PDGF). One patient underwent amputation during the healing process secondary to ongoing sepsis. Twenty of 21 patients healed acutely (within 6 months). Three of 20 patients went on to subsequent below knee amputation within 12 months of healing primarily. At 2 years, 12 of 21 (57%) were ambulating independently, 1 of 21 was dead, 4 of 21 had undergone amputation, 4 (19%) had limbs that were intact but were not ambulating. A total limb salvage rate of 76% at 2 years mirrored the secondary patency rates, with 100% follow up. Heel ulcers require multimodality therapy if they are going to have any chance to heal. We believe the algorithm presented allows for the required revascularisation and a modulation of the heel ulcer microenvironment by augmenting the microcirculation through NPWT, and improving the proliferative capacity with PDGF.     

Plantar Foot Ulcer Recurrence in Neuropathic Patients Undergoing Percutaneous Tendo-Achilles Lengthening

Equinus contracture carries 3- and 4-fold associations with diabetes and plantar foot ulceration, respectively. Percutaneous tendo-Achilles lengthening is a useful method to alleviate peak plantar pressure resulting from equinus. We aimed to evaluate the effectiveness of percutaneous tendo-Achilles lengthening and estimate the relative longevity of the approach in reducing ulcer recurrence. The medical records of patients with equinus contracture who underwent percutaneous tendo-Achilles lengthening from 2010 to 2017 were reviewed. Included patients presented with plantar ulcers and a gastroc-soleus equinus of any angle <10° of ankle dorsiflexion with the affected knee extended and flexed. Patients who received concomitant tendon lengthening procedures (including anterior tibial tendon or flexor digitorum longus) were excluded. Outcome measures included time to wound healing, time to ulcer recurrence, and development of transfer lesion. Ninety-one patients underwent percutaneous tendo-Achilles lengthening with subsequent pedal ulceration without concomitant procedures. A total of 69 (75.8%) patients had a plantar forefoot ulcer, 7 (7.7%) had midfoot ulcers, 5 (5.5%) had hindfoot ulcers, and 3 (3.3%) had ulcers in multiple locations. Seven patients received prophylactic tendo-Achilles lengthening. At a mean follow-up of 31.6 months (±26), 66 (78.6%) wounds healed at a median 12.9 weeks. A total of 29 patients (43.9%) experienced ulcer recurrence at a mean of 12 months. Twelve patients (13%) experienced a transfer lesion at a mean of 16.6 months. Tendo-Achilles lengthening can be an effective adjunctive approach to achieve wound healing and reduce long-term ulcer recurrence in patients with equinus contracture and neuropathic plantar foot ulcers. A relengthening procedure may be needed within approximately 12 months from index surgery.     

Local signs and symptoms in relation to final amputation level in diabetic patients: A prospective study of 187 patients with foot ulcers

Local signs and symptoms were evaluated in 187 consecutively presenting diabetic patients undergoing amputation for foot ulcers. From admission until final outcome the patients were treated by the same multidisciplinary team both as in- and outpatients. At the time of amputation, the types of lesions were superficial/deep ulcer (n 17), ulcer with deep infection, but without gangrene (n 40), and gangrene with or without infection (n 130). Healing after a minor amputation (below the ankle) occurred in 74 patients, while 88 patients healed after a major amputation (above the ankle), and 25 patients died before healing had occurred. Deep infection and presence of popliteal or pedal pulses were associated with healing after minor amputation and so were ulcers on the small toes, metatarsal head area and midfoot. Pain, progressive gangrene, intermittent claudication, and decubital and multiple ulcers were related to healing after major amputation. In a logistic regression analysis, pain, progressive gangrene and intermittent claudication remained. However, none of these factors excluded healing of a minor amputation and thus selection of amputation level in diabetic patients with foot ulcers cannot be based upon these factors exclusively.     

Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing

HYPOTHESIS: In patients with diabetic foot and pressure ulcers, early intervention with biological therapy will either halt progression or result in rapid healing of these chronic wounds. DESIGN: In a prospective nonrandomized case series, 23 consecutive patients were treated with human skin equivalent (HSE) after excisional debridement of their wounds. SETTING: A single university teaching hospital and tertiary care center. PATIENTS AND METHODS: Twenty-three consecutive patients with a total of 41 wounds (1.0-7.5 cm in diameter) were treated with placement of HSE after sharp excisional debridement. All patients with pressure ulcers received alternating air therapy with zero-pressure alternating air mattresses. MAIN OUTCOME MEASURE: Time to 100% healing, as defined by full epithelialization of the wound and by no drainage from the site. RESULTS: Seven of 10 patients with diabetic foot ulcers had complete healing of all wounds. In these patients 17 of 20 wounds healed in an average of 42 days. Seven of 13 patients with pressure ulcers had complete healing of all wounds. In patients with pressure ulcers, 13 of 21 wounds healed in an average of 29 days. All wounds that did not heal in this series occurred in patients who had an additional stage IV ulcer or a wound with exposed bone. Twenty-nine of 30 wounds that healed did so after a single application of the HSE. CONCLUSIONS: In diabetic ulcers and pressure ulcers of various durations, the application of HSE with the surgical principles used in a traditional skin graft is successful in producing healing. The high success rate with complete closure in these various types of wounds suggests that HSE may function as a reservoir of growth factors that also stimulate wound contraction and epithelialization. If a wound has not fully healed after 6 weeks, a second application of HSE should be used. If the wound is not healing, an occult infection is the likely cause. All nonischemic diabetic foot and pressure ulcers that are identified and treated early with aggressive therapy (including antibiotics, off-loading of pressure, and biological therapy) will not progress.     

Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia

OBJECTIVE: To examine wound healing and the functional natural history of patients undergoing infrainguinal bypass with reversed saphenous vein for critical limb ischemia (CLI). METHODS: Consecutive patients undergoing infrainguinal bypass for CLI were retrospectively entered into a technical and functional outcomes database. The patients were enrolled from the tertiary referral vascular surgery practices at the University of Colorado Health Sciences Center and Southern Illinois University Medical School. Main outcome variables included wound healing, self-assessed degree of ambulation (outdoors, indoors only, or nonambulatory), and living status (community or structured) after a mean follow up of 30 +/- 23 months. These outcome variables were assessed relative to the preoperative clinical characteristics (symptom duration before vascular consultation, lesion severity, and serum albumin level) and graft patency. RESULTS: From August 1997 through December 2004, 334 patients (253 men; median age, 68 years) underwent 409 infrainguinal bypasses (157 popliteal, 235 tibial, and 17 pedal) for CLI (159 Fontaine III and 250 Fontaine IV). Perioperative mortality was 1.2%. At 1 and 3 years, respectively, the primary patency was 63% and 50%, assisted primary patency was 80% and 70%, limb salvage was 85% and 79%, and survival was 89% and 74%. Complete wound healing at 6 and 12 months was 42% and 75%, respectively. Thirty-four patients (10%) died before all wounds were healed. Multivariate analysis indicated that extensive pedal necrosis at presentation independently predicted delayed wound healing (P < or = .01). At baseline (defined as the level of function within 30 days before the onset of CLI), 91% of patients were ambulatory outdoors, and this decreased to 72% at 6 months (P < or = .01). Similarly, 96% of patients lived independently at baseline, and this decreased to 91% at 6 months (P < or = .01) Graft patency was associated with better ambulatory status at 6 months. A longer duration of symptoms before vascular consultation was associated with a worse living status at 6 months. CONCLUSIONS: Despite achieving the anticipated graft patency and limb salvage results, 25% of patients did not realize wound healing at 1 year of follow-up, 19% had lost ambulatory function, and 5% had lost independent living status. Prospective natural history studies are needed to further define the functional outcomes and their predictors after infrainguinal bypass for CLI.     

Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease

OBJECTIVE: The purposes of this study were to determine whether autogenous arterial grafts to distal pedal arteries improve the patency of grafts and limb salvage in patients with end-stage renal disease and nonhealing ischemic wounds and to better define the indications for autogenous arterial grafts. DESIGN: A review of consecutive patients with end-stage renal disease undergoing autogenous arterial grafts from 1994 through 1999 was carried out. The setting was a university hospital. All 11 patients with end-stage renal disease and nonhealing, ischemic wounds (stage IV SVS-ISCVS classification) undergoing autogenous arterial grafting from 1994 to 1999 were evaluated. Noninvasive studies confirmed inadequate perfusion pressures in all patients. Pre-bypass arteriography identified no major arteries patent at the level of the malleolus, with reconstitution of only a distal or branch pedal or plantar vessel less than 1 mm in diameter. Five patients with patent tibial vessels to just above the ankle underwent bypass surgery with autogenous arterial grafts alone. Six patients also had proximal occlusive disease that required grafts longer than the autogenous arterial grafts; in each of these six patients, an autogenous vein graft proximal to the autogenous arterial graft was placed through use of a composite technique. Inflow was from the common femoral artery in one patient, the popliteal artery in five patients, and a tibial artery in five patients. Outflow was to the medial plantar artery in five patients, the distal dorsalis pedis artery in three patients, the lateral plantar artery in two patients, and the superficial arch in one patient. The conduit was the subscapular artery in four patients, the deep inferior epigastric artery in four patients, the superficial inferior epigastric artery in two patients, and the radial artery in one patient. The main outcome measures were assisted primary graft patency and functional limb salvage rate. RESULTS: Follow-up ranged from 6 to 63 months (mean, 20 months); graft patency was determined by means of duplex scanning. All 11 patients are alive, and nine grafts are patent, including three after revision for graft stenosis. Assisted primary patency was 82% at 3 years. All nine patients with patent grafts remained ambulatory and had healed wounds or limited forefoot amputations. CONCLUSION: Autogenous arterial grafts were effective in treating limb-threatening ischemia in patients with end-stage renal disease and inframalleolar arterial insufficiency. Graft patency and limb salvage rates were higher than those reported for autogenous vein graft in these patients. Autogenous arterial grafting may therefore prove to be an effective alternative to autogenous vein grafting in selected patients.     

Angiosome指导下膝下动脉成形术治疗合并糖尿病的Fontaine1V级下肢动脉缺血

目的探讨Angiosome指导下膝下动脉成形术的临床价值。方法2011年1月～2012年2月20例合并糖尿病的FontaineIV级缺血（ABI：0．10～0．22,平均0．15）,按照Angiosome概念评价足部破损区域的靶血管并开通,其中胫前动脉7例,胫后动脉10例,胫前后动脉3例。患肢股浅动脉顺行穿刺,应用V18导丝及Reekross18球囊导管开通闭塞的靶血管,AmphirionDeep球囊行成形术。术后即时测定患肢踝肱指数（anklebrachialindex,ABI）,术后1、3、6个月采用血管多普勒和CTA／NCMRA以及局部切口愈合情况评价血管开通、通畅性和创面修复情况,同时记录有无截肢事件发生。结果20例均成功开通靶血管,无相关并发症发生。术后即时AB10．86±0．06,较术前0．154-0．03显著提高（t=-45．603,P=0．000）。术后1、3、6个月时靶血管的通畅率分别为100％（20／20）、95％（19／20）、75％（15／20）。术后6个月保肢率为100％,85％（17／20）的患肢6个月时完全愈合。结论Angiosome指导下膝下动脉成形术治疗合并糖尿病的FontaineIV级缺血安全可行,有助于保肢及促进创面愈合的治疗。     

Lateral plantar artery bypass grafting: defining the limits of foot revascularization

We placed 20 bypass grafts to the lateral plantar artery in 18 extremities to salvage feet with wet (12) or dry (six) gangrene; 15 grafts were implanted in men (75%), and five were implanted in women (25%). The median age was 65 years. All except two patients had diabetes; eight were treated with insulin. One patient had Buerger's disease, and another had vasculitis with chronic lymphocytic leukemia. History of smoking (65%), hypertension (53%), heart disease (71%), and osteomyelitis in the foot (35%), were noted. Cultures were positive in 15 gangrenous feet, 11 with gram-negative bacilli. Four long femoroplantar bypasses were placed. Ten short grafts were placed from the popliteal artery, and six jump grafts were placed distal to a femoropopliteal or tibial bypass. Hospital stay ranged from 8 to 38 days (median 16 days), and there were two in-hospital deaths. Transmetatarsal or button toe amputations were performed in nine feet. There were two below-knee amputations, one with a patent graft, for a foot salvage rate of 89% at 2 months. In four instances the gangrenous ulcers took longer than 6 months to heal; all other wounds healed within 6 months. The primary and secondary patency rates were 85% at 1 month, and 73% at 3 months and thereafter. Four of five graft failures occurred in the two legs with repeat bypass graftings. All patients with successful revascularization are able to walk, and seven returned to work full time.     

Silverhawk斑块切除成形治疗严重膝下动脉硬化闭塞性病变

目的：探讨Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞性病变的安全性和有效性。 方法：回顾分析2年来治疗的9例该病患者临床与随访资料。其中男性3例,女性6例,平均年龄（64.0±9.1）岁,病程（28.9±25.9）个月;下肢间歇性跛行5例,静息痛1例,足趾溃疡1例,坏疽2例;6例病变位于胫腓干动脉,1例位于胫前动脉,2例位于胫后动脉;1例行单纯斑块切除,余8例患者均同时采用介入技术处理了流入道动脉病变。 结果：所有手术均获得成功。出院时所有患者再通血管保持通畅。跛行患者跛行距离均增至500 m以上,1例静息痛术后缓解,1例足趾溃疡面积缩小,2例坏疽呈干性无感染。患者术后踝肱比值（ABI）均较术前增加。所有患者得到随访,平均时间为（24.0±9.5）个月。1例患者术后23个月因心肌梗死死亡;1例患者间歇性跛行距离较术后最好时期有所减少,但仍优于术前;静息痛患者疼痛症状消失;溃疡患者伤口愈合;2例坏疽患者,1例仍保持干性状态,另1例其坏疽两趾脱落,创面愈合。 结论：Silverhawk斑块切除成型治疗严重膝下动脉硬化闭塞病变是一种安全有效的方法,是否能够成为一种常规的技术,还需要随机对照研究远期结果的验证。

     

Efficacy of dorsal pedal artery bypass in limb salvage for ischemic heel ulcers.

PURPOSE: Although pedal artery bypass has been established as an effective and durable limb salvage procedure, the utility of these bypass grafts in limb salvage, specifically for the difficult problem of heel ulceration, remains undefined. METHODS: We retrospectively reviewed 432 pedal bypass grafts placed for indications of ischemic gangrene or ulceration isolated to either the forefoot (n = 336) or heel (n = 96). Lesion-healing rates and life-table analysis of survival, patency, and limb salvage were compared for forefoot versus heel lesions. Preoperative angiograms were reviewed to evaluate the influence of an intact pedal arch on heel lesion healing. RESULTS: Complete healing rates for forefoot and heel lesions were similar (90.5% vs 86.5%, P =.26), with comparable rates of major lower extremity amputation (9.8% vs 9.3%, P =.87). Time to complete healing in the heel lesion group ranged from 13 to 716 days, with a mean of 139 days. Preoperative angiography demonstrated an intact pedal arch in 48.8% of the patients with heel lesions. Healing and graft patency rates in these patients with heel lesions were independent of the presence of an intact arch, with healing rates of 90.2% and 83.7% (P =.38) and 2-year patency rates of 73.4% and 67.0% in complete and incomplete pedal arches, respectively. Comparison of 5-year primary and secondary patency rates between the forefoot and heel lesion groups were essentially identical, with primary rates of 56.9% versus 62.1% (P =.57) and secondary rates of 67.2% versus 60.3% (P =.50), respectively. CONCLUSION: Bypass grafts to the dorsalis pedis artery provide substantial perfusion to the posterior foot such that the resulting limb salvage and healing rates for revascularized heel lesions is excellent and comparable with those observed for ischemic forefoot pathology.     

Off-loading of hindfoot and midfoot neuropathic ulcers using a fiberglass cast with a metal stirrup

BACKGROUND: This study was designed to assess the effectiveness of a method of off-loading large neuropathic ulcers of the hindfoot and midfoot. The device used is composed of a fiberglass cast with a metal stirrup and a window around the ulcer. METHODS: A retrospective study of 14 diabetic and nondiabetic patients was performed. All had chronic plantar hindfoot or midfoot neuropathic ulcers that failed to heal with conventional treatment methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer to allow daily ulcer care. RESULTS: The average duration of ulcer before application of the metal stirrup was 26 + 13.2 (range 7 to 52) months. The ulcer completely healed in 12 of the 14 patients treated. The mean time for healing was 10.8 weeks for midfoot ulcers and 12.3 weeks for heel ulcers. Complications developed in four patients: three developed superficial wounds and one developed a full-thickness wound. In three of these four patients, local wound care was initiated, and the stirrup cast was continued to complete healing of the primary ulcer. CONCLUSIONS: A fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient compliance. The window around the ulcer allows for daily wound care, drainage of the ulcer and the use of vacuum-assisted closure (VAC) treatment. The complication rate is comparable to that of total contact casting.     

Partial calcanectomy: an alternative to below knee amputation

Twenty-two patients with non-healing wounds over the heel, with or without underlying osteomyelitis, had been unresponsive to conservative therapy. They were treated with a partial calcanectomy as an alternative to below knee amputation. Nine patients had a primary diagnosis of diabetes. Thirteen patients had osteomyelitis from various other causes. All patients had a minimum 12 months follow-up except three who were deceased. Average follow-up was 27 months (range, two to 80 months). All patients healed their wounds with no patient requiring subsequent below knee amputation. Twelve patients had delayed wound healing including all nine with diabetes. Eleven additional procedures were performed on the heels of nine patients. Of the 18 patients available for follow-up at this time (four patients had died), all were satisfied with their surgery. Twelve were using orthoses while six used athletic shoes. Pain with activity was described as none in six, mild in 10, moderate in one, and severe in one patient with RSD. Ability to walk improved in seven, did not change in 10, and decreased in one (due to unrelated problems with his diabetes). Only one patient would have chosen a below knee amputation in hindsight due to pain in his lower leg and ankle. Partial calcanectomy is a viable alternative to below knee amputation with a high satisfaction level for patients with large heel ulcers with or without osteomyelitis.     

Safety of vein bypass grafting to the dorsal pedal artery in diabetic patients with foot infections.

The results of 56 vein bypasses to the dorsal pedal artery performed in 53 diabetic patients who were admitted with ischemic foot lesions complicated by infection were reviewed. All patients had one or more of the following: infected ulcers (73%), cellulitis (45%), osteomyelitis (29%), gangrene (20%), or abscess (2%). Organisms were cultured from 84% of patients (average 2.6, range 1 to 9 organisms per infection). Elevated temperature (greater than 37.7 degrees C) or leukocytosis (greater than 9.0 x 10(3)/ml) were seen in 13% and 50% of patients, respectively. All patients were treated with broad-spectrum antibiotics, local debridement, wound care, and bed rest. Operative debridement or open partial forefoot amputation were required to control sepsis in 11 patients (20%). Treatment of infection delayed revascularization by an average of 10.7 days. All patients underwent autogenous vein bypasses to the dorsal pedal artery. Two grafts failed within 30 days (3.6%), and one patient died (1.8%). Wound infections developed in seven patients (12.5). One wound infection resulted in graft disruption and patient death at 2 months. Average length of stay of the initial hospitalization was 29.8 days. Fifty-two patients were discharged with patent grafts and salvaged limbs; however, 31 subsequent foot procedures and 35 rehospitalizations were required to ultimately achieve foot healing. Actuarial graft patency and limb salvage were 92% and 98%, respectively at 36 months. Pedal bypass to the ischemic infected foot is efficacious and safe as long as infection is adequately controlled first. The complexity of these situations often requires multiple surgical procedures and extensive wound care, resulting in prolonged or multiple hospitalizations.     

Salvage of ischemic diabetic feet: role of transcutaneous oxygen mapping and multiple configurations of in situ bypass

Salvage of ischemic diabetic feet with advanced infrapopliteal and pedal arch atherosclerosis requires distal revascularization to heal skin envelope injuries. A series of 60 consecutive diabetic extremities with 41 nonhealing skin envelopes requiring distal tibial or pedal bypass in 83 percent has been reported. Four configurations of in situ bypass, including femoropopliteal, femorotibial, femoral sequential popliteal-tibial, and popliteal-tibial [3,9,11,17] were utilized with reversed and nonvein bypass to achieve a 93 percent hospital survival rate and 90 percent limb salvage with 80 percent graft patency at 36 months. Transcutaneous oxygen mapping was used to predict the healing of skin envelope injuries and late amputations after bypass. Postoperatively, limbs with transcutaneous oxygen values at the midfoot and surrounding skin injuries of more than 30 mm Hg rapidly healed, whereas those with midfoot values of more than 30 mm Hg but transcutaneous values surrounding skin injuries of less than 30 mm Hg had wound complications (p less than 0.001). Optimal limb salvage can be achieved with in situ bypass, sequential grafting, and high forefoot amputations if necessary. Transcutaneous mapping accurately predicts tissue healing and allows planning of the site and timing of late amputations.     

Arterial reconstruction of vessels in the foot and ankle.

OBJECTIVE: This study demonstrated that arterial reconstruction of vessels of the foot and ankle can preserve the majority of ischemic extremities with extensive tibial and peroneal occlusive disease and patent pedal arteries. SUMMARY BACKGROUND DATA: There are successful reports of bypass procedures to the ankle and foot, but despite this, these procedures have not gained widespread acceptance among surgeons performing infra-inguinal revascularization. Primary amputation is often offered for such patients. For this reason, the authors have reviewed their experience with bypasses to the foot and ankle. METHODS: A retrospective review was done of 75 arterial bypasses (5 bilateral), done since 1985, to the ankle and foot in 70 patients (38 males and 32 females). Fifty-four (77%) of the patients were diabetic. The age ranged from 55 to 95 years. Twenty-six (37%) were older than 80 years. The patients were selected for operative intervention because of severe tibioperoneal occlusive disease with ischemic rest pain or gangrene of the foot. Digital subtraction arteriography facilitated visualization of distal vessels. Operative principles included regional anesthesia, autogenous graft material, short bypass, non-traumatic vessel occlusion, selective operative arteriography, tension free ankle and foot skin closure, and concomitant conservative debridement of infected devitalized tissue. Incomplete pedal arch did not influence decision for operation. Indications for operation were: gangrene, 42 (56%); non-healing ulcer, 21 (28%); and rest pain, 12 (16%). Graft material was in situ greater saphenous vein, 40 (53%); translocated greater saphenous vein, 19 (25%); reversed greater saphenous vein, 11 (15%); and arm vein, lesser saphenous vein or vein patch, 5 (7%). Donor artery was popliteal, 30 (41%); common femoral, 26 (35%); and superficial femoral, 17 (23%). Recipient vessel was dorsalis pedis, 43 (57%); posterior tibial, 18 (24%); distal anterior tibial, 9 (12%); and distal peroneal, plantar or tibial endarterectomy, 5 (7%). RESULTS: There were four (5.7%) deaths and three (4.2%) graft failures within 30 days. Early graft failure led to transmetatarsal amputation (1), below knee amputation (1), and conversion of graft to femoral (1), popliteal bypass graft with limb salvage (1). In one patient, significant tissue necrosis with infection necessitated a below knee amputation within 30 days, despite a patent graft. Long-term follow-up revealed 10 graft failures, 4 major amputations, 3 graft revisions, and 15 deaths. Cumulative primary and secondary patency was 79.0% and 81.6% at 36 months. Limb salvage was 87.5% at 36 months. CONCLUSIONS: These results support an aggressive approach to limb salvage in patients with threatened limb loss, unreconstructable tibio-peroneal occlusive disease, and patent pedal arteries. Bypasses to the ankle and foot will maintain a functional extremity in the majority of these patients.     

A clinical trial of laser thermal angioplasty in patients with advanced peripheral vascular disease.

A 3-year prospective trial of laser thermal-assisted balloon angioplasty in 28 patients included 27 who had advanced peripheral vascular disease (severe tissue loss, gangrene, infection, and rest pain), 7 who were failures of previous therapy (surgery and thrombolysis), and 4 who were high risk for operation (myocardial infarction within 6 weeks and/or ejection fractions of less than or equal to 20%). Laser angioplasty was performed in the operating room via a groin incision by a surgeon-radiologist team. In the 27 patients with advanced peripheral vascular disease (ankle-brachial systolic pressure index [ABI] 0.27 +/- 0.2 in 10 nondiabetic, and 0.46 +/- 0.1 in 17 diabetic patients), recanalization of the native vessel was successful in 16, and patency was restored in 2 chronically occluded polytetrafluorethylene (PTFE) grafts. In these 18 (67%) successfully recanalized patients, however, five amputations were required within 1 month, and another six were needed between 8 and 12 months. Early amputations were caused by a failure of wound healing, even through angioplasty sites were patent. Late amputations were caused by reocclusion of the treated site in five of six patients. In the remaining seven patients in whom laser angioplasty alone was successful, five had healed limbs at 6 to 24 months and two remain incompletely healed but functional. The patency for successful procedures ranged from 48 hours to 25 months (5.6 +/- 6.4 mean months, +/- SD), with cumulative patency by life-table analysis of 55.5% at 3 months, 38.8% at 6 months, and 11.1% at 12 months. There were no procedure-related deaths. Complications included seven arterial wall perforations by the laser probe. We conclude that laser angioplasty has a limited role in advanced peripheral vascular disease but may provide an interval patency, thus allowing postponement of operation for high-risk patients until their medical conditions permits surgery, or to correct local tissue necrosis or infection in the operative field before reconstruction, and to restore patency to thrombosed PTFE grafts.     

Neuropathic plantar forefoot ulcers treated with tendon lengthenings

BACKGROUND: Foot ulcers are a common cause of infection and amputation in patients with neuropathy. This retrospective study evaluated the healing and recurrence rates after treating neuropathic ulcers plantar to the metatarsal heads with tendon lengthenings in the leg. MATERIALS AND METHODS: Between 1995 and 2003, 20 ulcers plantar to the metatarsal heads in 17 patients were treated with tendon lengthenings. All patients had gastroc-soleus recession (Vulpius procedure). Patients with first metatarsal head ulcers also had Z-type lengthenings of the peroneus longus. Patients with fifth metatarsal head ulcers also had intramuscular lengthening of the tibialis posterior. Patients with second, third, and fourth metatarsal head ulcers had only a gastroc-soleus recession. RESULTS: All patients had neuropathy; 15 patients with 17 ulcers had diabetes mellitus. All incisions healed primarily without infection. Nineteen of 20 ulcers healed. One patient with one ulcer was lost to followup after the ulcer healed. Average followup for the remaining 19 ulcers was 45 months. Average duration of the 19 ulcers before surgery was 17 months. Three of 19 ulcers recurred and had repeat tendon lengthening and healed again. None of the patients whose ulcers healed had to be admitted for foot infection or amputation. The one patient whose ulcer did not heal developed progressive dry gangrene which required trans-femoral amputation six months after tendon lengthening. CONCLUSION: Tendon lengthenings in the leg seem to be effective in healing and preventing recurrence of neuropathic ulcers plantar to the metatarsal head with a low complication rate.     

Outcomes of conventional wound treatment in a comprehensive wound center

Conventional wound care is the elementary treatment modality for treating chronic wounds. However, early treatment with topical growth factors may be needed for a subset of chronic wounds that fail to heal with good wound care alone. A prospective nonrandomized case series from a single-community outpatient wound care clinic is presented here in an effort to identify the subset of chronic wounds that may require early adjuvant intervention. There were 378 consecutive patients with 774 chronic wounds of varying etiology. All patients received 4 weeks of conventional wound care, including weekly debridement and twice-daily dressing changes. Wounds not reduced by 50 per cent volume at 4 weeks were nonrandomly treated with human skin equivalent (Apligraf), platelet-derived wound healing factor, or platelet-derived growth factor isoform BB (becaplermin gel, Regranex). A total of 601 of 774 (78%) wounds healed regardless of treatment type. The median time to heal for all wounds was 49 days (interquartile range = 26-93). More women than men healed (85% vs 71%, respectively, P < 0.0001). Diabetic wounds were as likely to heal as nondiabetic wounds (78% vs 80%, P = 0.5675). Wounds that did not heal had larger volumes and higher grade compared with wounds that healed (P < 0.0001 for both variables). The data presented here show that the majority of chronic wounds will heal with conventional wound care, regardless of etiology. Large wounds with higher grades are less responsive to conventional wound care and will benefit from topical growth factor treatment early in the treatment course.