A Review of Consecutive Cases to Identify the Rate of Underlying Osteomyelitis in Patients Undergoing Surgical Treatment of Gangrene of the Forefoot and Impact of Acute Infection on Outcome Following Amputation

Medical literature offers no clear treatment guidelines when performing amputations for gangrene of the forefoot despite a high percentage that suffer poor outcome due to infection. Gas gangrene and wet gangrene are often preceded by dry stable gangrene. This is a retrospective review of consecutive patients who underwent forefoot amputation and bone biopsy as treatment of forefoot gangrene by a single surgeon. Procedures performed included digital, ray, or transmetatarsal amputation with bone biopsy sent for both culture and histopathologic evaluation. One hundred patients (35 females, 65 males) met inclusion criteria. Mean follow-up was 9.6 months. Mean age was 63.5 years old. Forty-six out of 100 (46%) had elective amputation while 54/100 (54%) were emergent for acute infection. Vascular intervention was performed in 52/100 (52%). Seventy-eight out of 100 (78%) had histopathologic diagnosis of acute osteomyelitis while 82/100 (82%) had positive bone culture. Patients with acute infection had worse outcomes, with higher rates of more proximal amputation and delayed wound healing. We found that 79.7% of patients who underwent forefoot amputation due to gangrene had underlying osteomyelitis. We also found that those with acute infection during the time of amputation had poorer postamputation outcomes such as delayed wound healing, revision surgery, and high rates of more proximal amputation. Therefore, it may imply that earlier amputation of stable gangrene prior to becoming acutely infected may decrease the occurrence of osteomyelitis and avoid some of the preventable postamputation complications. Further studies are warranted.     

Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.     

Proportion of patients with critical limb ischemia who require an open surgical procedure in a center favoring endovascular treatment

Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.     

Predictors of failure of endovascular revascularization for critical limb ischemia

Background and Aims: To characterize predictors of failure when treating critical limb ischemia (CLI) patients with an endovascular intervention as the first-line strategy.Patients and Methods: This retrospective, registry-based study included 217 consecutive pa-tients with 240 chronic critically ischemic limbs treated with infrainguinal percutaneous trans-luminal angioplasty (PTA) during 2006-2007 at Helsinki University Central Hospital, Finland.The primary outcome measures were death, major (above-ankle) amputation, and the need for surgical re-intervention within 6 months after the primary procedure. The secondary out-come measures were overall major amputation and survival rates as well as the overall need for surgical or any other (surgical or endovascular) type of re-intervention.Predictors of outcome endpoints were identified with a univariate screen, and a Cox regres-sion model was used in the multivariate analysis.Results: Compared to ulcer, gangrene was significantly more strongly associated with ampu-tation within 6 months post-procedurally as well as during the whole follow-up period (p?≤?0.028). The patient's inability to walk upon hospital arrival was a significant predictor of death, amputation and surgical re-intervention.Mediasclerotic ankle-brachial index (ABI) was an independent predictor of amputation as well as endovascular re-interventions.Conclusions: The strong predictors of poor outcome after endovascular revascularization for patients with CLI are cardiac morbidity, the inability to ambulate upon hospital arrival, and gangrene as a manifestation of CLI. The risk of amputation seems to be significantly higher for gangrene than for ulcer and this matter should be taken into account in the clinical classifica-tions for CLI.     

Claudication in the setting of plethysmographic criteria for resting ischemia: Is surgery justified?

Objective noninvasive criteria for resting ischemia are sometimes found in patients with milder clinical complaints. If noninvasive information can predict irrevocable progression to resting ischemia, instances of tissue loss theoretically could be prevented by early intervention. Accordingly, we investigated the clinical outcome in 51 claudicators with pulse volume recorder and/or ankle-brachial index (ABI) criteria for ischemia at rest. Patients with type IV (markedly blunted) or type V (flat) ankle or transmetatarsal pulse volume recordings and/or ABI <0.5 and accompanying claudication were identified. Resting ischemia and/or tissue necrosis developed in 29% of patients and necessitated vascular reconstruction within 36 months. One patient had a primary above-knee amputation at a different institution and 14 patients underwent successful revascularization. In 3 of 14 patients, reconstruction was accompanied by digit or transmetatarsal amputation. No limbs were lost in the revascularized group. Noninvasive criteria for resting ischemia in patients with claudication alone portend a high rate of progression to resting ischemic symptoms. At present the use of clinical criteria and careful follow-up would permit a high rate of foot and limb salvage in those whose ischemia progresses and would prevent unnecessary surgery in the remaining patients. Further prospective definition of patients at risk for progression of ischemia might help prevent tissue loss in selected patients.Presented at the New England Society for Vascular Surgery, Dixville Notch, N.H., September 23, 1992.     

The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia

OBJECTIVES: A consequence of delay in the diagnosis of peripheral vascular disease limb loss. This study was undertaken to determine the correlation of low socioeconomic status and race on the severity of ischemic presentation and the subsequent amputation rate. METHODS: Data from the Nationwide Inpatient Sample (NIS) from 1998 to 2002 on patients from urban hospitals with the diagnosis of lower extremity ischemia were evaluated. The population was divided into two groups: the amputation group (AMP) and lower extremity revascularization group (LER). Comorbidities, age, gender, race, ischemic gangrene at presentation, insurance status (no/noncommercial or commercial), and income status at admission were determined. These variables were compared using multivariate logistic regression analyses of the data for risk adjustment. RESULTS: Of 691,833 patients presenting with lower extremity ischemia, 363,193 underwent revascularization (66.3%) or amputation (33.7%). Univariate analysis correlated a statistically significant (P < .0001) higher rate of amputation and multivariate analysis associated significantly higher odds of amputation with the following variables: nonwhites (1.91, 95% confidence interval [CI], 1.65, 2.20), low-income bracket (1.41, 95% CI, 1.18, 1.60), and Medicare & Medicaid (1.81, 95% CI, 1.66, 1.97). Adjusting for other variables of statistical significance, multivariate regression analysis showed a statistically significant risk for amputation based on the nonteaching status of the institution (odds ratio [OR], 1.17, 95% CI, 1.08, 1.30). CONCLUSIONS: Primary amputation was performed with a higher frequency on patients with lower extremity ischemia who were nonwhite, low income, and without commercial insurance. The observed advanced ischemia among these economically disadvantaged patients suggests a delayed diagnosis of peripheral vascular disease, probably due to lack of access to adequate primary care or vascular surgery providers, or both. Better education of the general population and primary care providers to the symptoms and consequences of PVD may reduce the amputation rate in this group.     

Intravenous infusion of prostaglandin E1 (PGE1) in management of limb ischemia

Twenty-three patients who had advanced arteriosclerotic disease of the lower extremities as manifested by rest pain, nonhealing ischemic ulcers, or impending gangrene and who were not candidates for direct arterial revascularization procedure underwent intravenous infusion of prostaglandin E1 (PGE1). Thirty-nine per cent of the patients showed subjective and/or objective improvement in the blood supply, and in 22 per cent (5 patients) amputation was avoided. Complications were minor and disappeared once the infusion was discontinued. PGE1 in prescribed dosages can be safely infused intravenously. Even though the results are not as encouraging as when PGE1 is given by the intra-arterial route, IV therapy improves the ischemic symptoms and avoids the necessity of amputation in some patients.     

Microvascular free tissue transfer after arterial revascularization in the elderly: an alternative to amputation

Extensive tissue loss associated with ischemia is a common problem in the elderly population with vascular insufficiency. This study involves 3 patients who underwent free tissue transfer following arterial revascularization for limb salvage. Latissimus dorsi, internal oblique muscles, and temporoparietal fascia free flaps were used. Two patients had the recipient vessel reconstituted by collaterals after complete atherosclerotic occlusion. There were no postoperative complications, and the reconstructive procedure never precipitated ischemia of the revascularized extremity. We conclude that free tissue transfers can be performed safely with good functional results in elderly patients. Such transfers should be considered an alternative to amputation and a rational step after arterial revascularization for limb salvage in patients with complex, nonhealing soft tissue defects.     

Limb-threatening and Life-threatening Diabetic Extremities: Clinical Patterns and Outcomes in 56 Patients

Limb- and life-threatening hand and foot infections in diabetic patients account for a large proportion of amputations and a substantial number of deaths. Between August 2006 and the end of July 2008, we conducted a prospective cohort study of consecutive diabetic patients with serious hand or foot infections, in an effort to identify clinical patterns and outcomes related to the treatment of these infections. Infections were categorized as dry, gas, and wet gangrene; necrotizing fasciitis or cellulitis; acute extensive osteomyelitis; and any of these infections involving the hand. All of the patients underwent a standard examination and treatment protocol, although none of the patients received vascular surgical care. End points included healing following debridement or minor amputation, major (transtibial or more proximal) amputation, or death. A total of 56 patients were included in the final analyses, and their mean age was 70 (range 51 to 86) years. Of the patients, 17 (30.36%) had necrotizing cellulitis, 12 (21.43%) had wet gangrene, 9 (16.07%) had acute extensive osteomyelitis, 5 (8.93%) had dry gangrene, 5 (8.93%) had gas gangrene, 4 (7.14%) had necrotizing fasciitis, and 4 (7.14) had diffuse hand infections. Five (8.93%) patients died (2 after prior amputation), 26 (46.43%) underwent debridement and/or minor amputation, and 27 (48.21%) required major amputations. Based on our findings, we concluded that 7 patterns of serious limb- or life-threatening infection were identified and, in the absence of vascular surgical intervention, mortality can be reduced at the expense of more amputations.     

Routine Use of Distal Arterial Perfusion in Pediatric Femoral Venoarterial Extracorporeal Membrane Oxygenation

Lower‐extremity ischemia is a significant complication in children on femoral venoarterial extracorporeal membrane oxygenation (VA ECMO). Our institution currently routinely uses distal perfusion catheters (DPCs) in all femoral arterial cannulations in attempts to reduce ischemia. We performed a single‐center, retrospective review of pediatric patients supported with femoral VA ECMO from January 2005 to November 2015. The outcomes of patients with prophylactic DPC placement at cannulation (prophylactic DPC) were compared to a historical group with DPCs placed in response only to clinically evident ischemic changes (reactive DPC). Ischemic complication requiring invasive intervention (fasciotomy or amputation) was the primary outcome. Twenty‐nine patients underwent a total of 31 femoral arterial cannulations, 17 with prophylactic DPC and 14 with reactive DPC. Ischemic complications requiring invasive intervention developed in 2 of 17 (12%) prophylactic DPC patients versus 4 of 14 (29%) reactive DPC. In the reactive DPC group, 7 of 14 (50%) had ischemic changes postcannulation, six underwent DPC placement, and three out of six of these patients still required invasive intervention. One of the seven patients had ischemic changes, did not undergo DPC, and required amputation. While a greater percentage of patients in the prophylactic group was cannulated during extracorporeal cardiopulmonary resuscitation (ECPR), statistical significance was not otherwise demonstrated. We demonstrate feasibility of superficial femoral artery (SFA) access in pediatric patients. We note fewer ischemic complications with prophylactic DPC placement, and observe that salvaging a limb with a reactive DPC was only successful 50% of the time. Although there was no statistical difference in the primary outcome between the two groups, limitations and confounding factors include small sample size and a greater percentage of patients in the prophylactic DPC group cannulated with ECPR in progress.     

Does open fasciotomy contribute to morbidity and mortality after acute lower extremity ischemia and revascularization?

A retrospective review was undertaken of 127 lower extremity fasciotomies performed for compartment syndrome after acute ischemia and revascularization in 73 patients with vascular trauma and 49 patients with arterial occlusive disease. One hundred twelve (88%) fasciotomies were performed early (at the time revascularization); 15 (12%) were delayed because of late compartment syndrome diagnosis. Ninety-four (77%) patients had more than one accepted indication for fasciotomy. Double-incision fasciotomy was used in 98 (77%) extremities, single-incision fasciotomy was used in 19 (15%), and fasciotomy-fibulectomy was used in 10 (8%). Fasciotomies were closed in 88 (69%) patients an average of 14 days after surgery. Seven patients needed multiple skin grafting procedures or myocutaneous flaps to close the wound; none compromised limb salvage. Five other patients had minor wound infections that resolved. Functional status returned to preoperative levels by the time of discharge from the hospital in 59 (48%) patients. Thirty-one (24%) patients had residual lower extremity disability related to delayed union of the fracture (five), chronic neuropathy (20), leg swelling (one), or ischemic nonhealing fasciotomy wounds (three); two patients had unrelated disabilities. Fourteen (11%) amputations were required for refractory limb ischemia; two (1.6%) were required for wet gangrene of the foot, which infected the fasciotomy site; the others had open noninfected incisions. Eighteen (15%) patients died of cardiopulmonary failure or multisystem failure or both, without fasciotomy-related problems. Open fasciotomy for compartment syndrome after acute lower extremity ischemia and revascularization was associated with an increased risk of minor wound morbidity. However, limb loss and death resulted from persistent ischemia and underlying systemic disease processes or injuries, but not from open fasciotomy wound complications.     

Natural history of claudicants with critical hemodynamic indices

We reviewed the records of approximately 1,500 patients seen in the Vascular Laboratory of the Cincinnati Veterans Affairs Medical Center from 1980 to 1987 and identified 23 patients (25 limbs) who metall of the following criteria: 1) an ankle/brachial index less than or equal to 0.35; 2) an ankle or transmetatarsal pulse volume recording less than or equal to 3 mm in amplitude; and 3) no history of ischemic rest pain or gangrene. These patients were followed in the Vascular Laboratory for periods ranging from 11 to 127 months (mean 45.2 months). The study was terminated in March 1991 or when revascularization or amputation was required for limb-threatening symptoms or if the patient expired. Thirteen extremities (52%) showed no progression to limb-threatening symptoms. Claudication actually improved in three, remained unchanged in eight, and progressed in two. Twelve (48%) extremities developed limb-threatening conditions, with rest pain occurring in three, ischemic ulceration in six and gangrene in three. Eight of these limbs underwent revascularization and only one ultimately required major amputation. Another extremity presented with extensive gangrene and underwent a primary above-knee amputation. Three other patients did not undergo revascularization because of death in one and refusal in two others. Patients with intermittent claudication who have critical hemodynamic indices are at much greater risk for developing symptomatic limb-threatening ischemia. Close follow-up is mandatory since nearly half of these patients will eventually require operation for limb salvage. Patients who are unlikely to comply with a regular follow-up program may be considered for early revascularization to prevent complications of limb-threatening ischemia.Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts.     

A reappraisal of a modified through-knee amputation in patients with peripheral vascular disease

BACKGROUND: Through-knee amputation provides a longer lever arm and improved muscle control of the limb compared with above-knee amputation. Through-knee amputation also allows use of a total end-bearing prosthesis, which avoids the ischial pressure and suspension belts required of the above-knee amputation prosthesis. Several reports in the European literature tout the superiority of the through-knee amputation over the above-knee amputation in the patient with vascular disease. Through-knee amputation has received little attention in the United States, however, owing to the belief that the long flaps necessary to close a standard through-knee amputation are associated with an unacceptable rate of wound problems and offer no functional ambulatory advantage to above-knee amputation. We reviewed our experience with a modified technique of through-knee amputation in a group of patients with severe lower extremity ischemia who were not candidates for below-knee amputation to determine the incidence of wound complications and their functional outcome. METHODS: Since 1996, 12 patients with severe lower extremity arterial insufficiency have undergone through-knee amputation utilizing a technique designed to limit flap length and facilitate the fit of a suction prosthesis. Two patients died of myocardial infarction in the immediate postoperative period and were excluded from the study. In the remaining 10 patients (1 man, 9 women; mean age 63 years (range 40 to 86), the below-knee amputation level was precluded because of gangrene or nonhealing wounds of the mid leg in 5 patients, failure of a previous below-knee amputation attempt in 4 patients, and severe ischemia that would compromise below-knee amputation healing in 1 patient. Nine patients had at least one failed vascular reconstruction procedure. RESULTS: Mean follow-up is 25 months (range 6 to 41). Six (60%) patients had primary healing of their amputations. Two (20%) patients had delayed healing (6 weeks and 8 weeks). Two (20%) patients developed wound infections, which required amputation revision to the above-knee level. Seven (70%) patients were fitted with a suction socket prosthesis and are fully ambulatory. One patient healed but has not ambulated because of ischemia and subsequent ulceration of the contralateral limb. CONCLUSIONS: These data show that through-knee amputation is associated with an acceptable primary healing rate (80%) and satisfactory functional outcomes (70% ambulation) in a high-risk vascular population. The functional advantages of through-knee amputation over above-knee amputation make it the preferred alternative for patients with vascular disease.     

Stumpferhalt und Stumpfverlängerung an der unteren Extremität

Despite new techniques and better health programs in western industrialized nations, the numbers of amputations on the lower extremity remain constant. Approximately 100,000 amputations are performed annually in the U.S. and about 10,000 in Germany, more than 90% for gangrene resulting from ischemia and/or infection. Micro- and macroangiopathic changes in diabetes are the major cause of ischemia in the leg. The preservation of limb length and construction of an end bearing stump are important criteria for the functional outcome after amputation. Especially in trauma and tumor patients with "planned" amputations, all effort should be made to achieve an end bearing stump with sufficient length respectively an amputation level that is suitable for orthosis instead of prosthetic supplementation. After amputation, an interdisciplinary approach is mandatory to achieve sufficient soft tissue coverage or stump distalization. In case of insufficient bearing ability of the stump, various reconstructive possibilities must be considered to assure optimal outcome.     

Venous gangrene of the upper extremity.

Gangrene of the hand associated with acute upper extremity venous insufficiency has been seen in four limbs in three patients treated at Vanderbilt University Medical Center. All three patients had life-threatening illnesses associated with diminished tissue perfusion, hypercoagulability, and venous injury. One patient progressed to above-elbow amputation, but venous thrombectomy in one limb and thrombolytic therapy in two others were successful in preventing major tissue loss. All three patients eventually died from their underlying illness. Thirteen previously reported patients with "venous gangrene" of the upper extremity have been analyzed. An underlying life-threatening illness was present in the majority of these patients (7/13, 54%) and, like the Vanderbilt series, amputations were frequent (7/13, 54%) and mortality (5/13, 38%) was high. This unusual form of ischemia appears to be produced by permutations of global circulatory stasis, subclavian or axillary vein occlusion, and peripheral venous thrombosis. Early, aggressive restoration of adequate cardiac output and thrombectomy and/or thrombolytic therapy may provide the best chance for tissue salvage and survival in this group of patients.     

Free vascularized tissue transfer for limb salvage in peripheral vascular disease

In patients with tissue necrosis, higher limb salvage rates can be accomplished with free tissue transfers performed by a vascular and plastic surgeon team. We treated 10 patients with severe ischemic soft tissue defects in their legs with radical debridement and free tissue transfer alone (two patients) or after revascularization (eight patients). Arteriography was performed to plan revascularization to evaluate bypass results, and to identify appropriate recipient vessels for free tissue transfer. Soft tissue defects treated with free tissue transfer included nonhealing amputation sites in five patients and proximal skin and muscle necrosis in the remaining patients, one of which resulted in an exposed in-situ graft in one leg. One patient underwent a distal bypass specifically to provide arterial inflow for free tissue transfer, whereas seven other patients received free tissue transfers following bypass due to persistently nonhealing wounds. The remaining two patients had diabetes mellitus with necrosis near a major joint with nonhealing amputation sites. Free tissue transfers were taken from the latissimus dorsi in six patients, and from the gracilis, rectus abdominis, rectus femoris, and scapula flaps in other patients. Recipient vessels for free tissue transfers were the external iliac artery (one patient), saphenous vein bypass grafts (two patients), popliteal artery (one patient), posterior tibial (three patients), and dorsalis pedis vessels (three patients). Eight of the 10 flaps were viable at follow-up (four months-six years), with a mean follow-up of 20 months. One patient underwent above-knee amputation 15 months after operation and one underwent below-knee amputation three years later due to central flap necrosis. The remainder achieved functional limb salvage allowing patients to resume ambulation. Vascular surgeons should consider free tissue transfer in patients with nonhealing soft tissue defects following optimal revascularization to further extend our ability to salvage the threatened limb.Presented at the Annual Meeting of the Peripheral Vascular Surgery Society, New York, New York, June 17, 1989.     

Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities

BACKGROUND: Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation. METHODS: We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic blockage of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buerger's disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intraarterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue. RESULTS: We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 +/- 0.4 days and mean postoperative hospital stay was 5.3 +/- 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation. CONCLUSIONS: Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease.     

Limb salvage vs amputation for critical ischemia. The role of vascular surgery

Since 1980, 498 patients with 627 critically ischemic legs (rest pain, gangrene, ischemic ulcer, and ankle-brachial pressure index less than 0.40) were treated with revascularization regardless of operative risk or anticipated operative difficulty. Primary amputation was performed only when no graftable distal vessels were present (14 primary amputations [2.8%]) or in neurologically impaired, hopelessly nonambulatory patients. The mortality for revascularization was 2.3%, and the median hospital stay was 11 days. During follow-up, 41 limbs (7%) required amputation, 31 after failure of revascularization and 10 despite patent revascularizations. Renal failure had an adverse influence on limb salvage (67%) because of a significantly increased requirement for amputation despite patent revascularizations. We conclude aggressive limb revascularization in patients with critical lower-extremity ischemia results in low operative morbidity and mortality and excellent long-term limb salvage. Patients with critical leg ischemia and renal failure are at higher risk for limb loss than patients without renal failure.     

Gangrene of the upper extremity in diabetic patients

Twenty-two patients who had diabetes mellitus and had needed an amputation for gangrene in an upper extremity at an average age of fifty-one years were identified and followed. The five patients who were still living at the latest follow-up had been followed for an average of 50.6 months. The other seventeen patients survived for an average of only 20.6 months after the amputation. All of the patients were in poor health; eighteen had needed an amputation in a lower extremity, and sixteen received hemodialysis. The results of amputation in an upper extremity were unsatisfactory; the site of the initial amputation healed in only two of the twenty-two patients. In the remaining twenty patients, a total of sixty-three additional operations were performed on an upper extremity, and five of the twenty patients died before the wound had healed.     

Epidural electrical stimulation in severe limb ischemia. Pain relief, increased blood flow, and a possible limb-saving effect.

Peripheral vascular disease of the extremities causes ischemic pain and, at times, skin ulcerations and gangrene. It has been suggested that epidural spinal electrical stimulation (ESES) could improve peripheral circulation. Since 1978 we have used ESES in 34 patients with severe limb ischemia; all had resting pain and most had ischemic ulcers. Arterial surgery was technically impossible. Twenty-six patients had arteriosclerotic disease, one had Buerger's disease, and seven had severe vasospastic disorders. Ninety-four per cent of the patients experienced pain relief. ESES healed ulcers in 50% of those with preoperative nonhealing skin ulcerations. Seventy per cent of the patients showed improved skin temperature recordings. Only 38% of the stimulated arteriosclerotic patients underwent amputations during a mean followup period of 16 months, as compared to 90% of a comparable group of unstimulated patients. ESES is very promising in severe limb ischemia where reconstructive surgery is impossible or has failed.