Functional outcome in a contemporary series of major lower extremity amputations.
(33/1399)
PURPOSE: We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS: A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS: From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS: We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor. (+info)
Cryopreserved saphenous vein allografts in infrainguinal revascularization: analysis of 240 grafts.
(34/1399)
INTRODUCTION: Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization. Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. RESULTS: Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. CONCLUSIONS: Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit. (+info)
Comparison of procedural outcomes after lower extremity reversed vein grafting and secondary surgical revision.
(35/1399)
OBJECTIVE: Many lower extremity vein graft procedures require revision. Although morbidity associated with revision procedures is assumed minimal, this has not been previously quantified and may be underestimated. In this study, patient outcome after initial vein graft procedures and revisions are compared. METHODS: Records for all patients undergoing vein graft revision from January 1995 to August 2002 were reviewed for operation time, estimated blood loss, blood transfusion, hospital length of stay, perioperative complications, and functional status at discharge and at 2-month follow-up. Revisions were compared with the original operation and by revision type. RESULTS: One hundred sixty-five vein graft revisions were performed in 137 patients. In comparison with the initial bypass procedure, mean operation time (3.35 +/- 1.41 hours vs 2.58 +/- 1.04 hours; P <.001), estimated blood loss (272.4 +/- 249.9 mL vs 174.8 +/- 140.8 mL; P <.001), hospital length of stay (10.15 +/- 4.85 days vs 7.05 +/- 5.14; P <.001), and overall complication rate (35.8% vs 22.4%; P =.015) were significantly less for revision procedures. Revision of more than one site on the graft resulted in longer operation time (P =.003) and estimated blood loss (P <.001), but similar complication rates (P = NS), compared with revision at only one site. Revisions that involved only the graft resulted in decreased hospital length of stay compared with revisions involving extension to native inflow or outflow vessels (P <.02). Return to preoperative ambulatory status at discharge was 71% after initial operation, and was 92% after revision (P <.001). Return to independent living at discharge was 66% after the initial operation, and was 80% after revision (P <.01). CONCLUSIONS: Operative revisions were better tolerated than initial vein graft procedures, but are still major procedures. Hospital length of stay is longer for patients undergoing proximal or distal extension of the graft to native vessels and in patients who are not ambulatory and living independently at discharge. Patients undergoing vein graft revision should be counseled about potential morbidity. (+info)
Treatment of limb-threatening ischemia with percutaneous intentional extraluminal recanalization: a preliminary evaluation.
(36/1399)
OBJECTIVE: We assessed the technical success, safety, and short-term effectiveness of percutaneous intentional extraluminal recanalization (PIER) in patients with limb-threatening ischemia and no autologous vein or with a major contraindication to surgery. METHODS: From 1999 through 2002, 25 patients with femoropopliteal occlusion and rest pain or tissue loss underwent PIER. Thirteen patients had undergone one or more failed bypass surgeries in the treated lower extremity, and no patient had suitable vein for bypass grafting. In four patients the ejection fraction was less than 15%; four patients had severe nonreconstructable coronary artery disease; and two patients with metastatic cancer refused amputation. All patients underwent subintimal wire placement, followed by percutaneous transluminal angioplasty and intracoil stent placement. Occlusions ranged in length from 6 to 18 cm, and 1 to 10 stents were placed. Technical success required no residual stenosis greater than 30% on arteriography, velocity ratio less than 1.5 on duplex ultrasound scanning, and improvement in ankle-brachial index of 0.15 or greater. Follow-up duplex scanning was performed every 3 months. RESULTS: Initial success was obtained in 23 of 25 patients (92%), with ankle-brachial index improvement of.31 to.54. All successful procedures resulted in symptomatic improvement. Mean follow-up was 13.3 months (range, 4-30 months). During follow-up, 10 patients died and 2 arteries demonstrated recurrent occlusion. With life table analysis, success rate was 92% at 12 months. Of the 4 patients in whom the procedure failed, 3 required major amputation and symptoms persisted in one. Complications occurred after two procedures, one myocardial infarction and one groin hematoma. CONCLUSIONS: PIER is technically possible in patients with femoropopliteal occlusion, and the procedure is associated with a low complication rate. Most procedures provide at least short-term clinical success and have enabled successful wound healing and pain relief in patients without other effective options. Further studies and longer follow-up are required to determine long-term success and the role of PIER in treatment of femoropopliteal occlusion. (+info)
Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis.
(37/1399)
OBJECTIVE: This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. METHODS: Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. RESULTS: Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). CONCLUSIONS: Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery. (+info)
Platelet activation is increased in peripheral arterial disease.
(38/1399)
OBJECTIVE: Platelet activation was assessed in patients with peripheral arterial disease compared with healthy control subjects. METHODS: This prospective comparative study included 100 subjects: 40 consecutive patients with intermittent claudication, 20 consecutive patients with critical ischemia and tissue loss, and 40 healthy control subjects. Whole blood flow cytometric analysis was performed to determine resting and stimulated platelet P-selectin expression and resting and stimulated platelet fibrinogen binding. Results are presented as platelet percentage and also as mean fluorescence intensity. RESULTS: P-selectin expression was significantly increased in patients with intermittent claudication (median, 0.85%; range, 0.31%-4.77%; P =.023) and critical ischemia (median, 1.11%; range, 0.2%-3.26%; P =.028) compared with control subjects (median, 0.59%; range, 0.16%-4.58%). The percentage of platelets binding fibrinogen was also significantly higher in patients with intermittent claudication (median, 2.89%; range, 1.08%-9.59%; P <.001) compared with control subjects (median, 1.57%; range, 0.17%-10.7%). There was no significant difference in percentage of platelet fibrinogen binding between control subjects and patients with critical ischemia. Fibrinogen binding by stimulated platelets was significantly diminished in patients with critical limb ischemia compared with control subjects (67.2% vs 77.9%; P =.006). CONCLUSIONS: Platelet activation is increased in patients with peripheral arterial disease, suggesting an underlying prothrombotic state. Platelets from patients with critical limb ischemia are less responsive to in vitro stimulation. (+info)
Localized extremity soft tissue sarcoma: improved knowledge with unchanged survival over time.
(39/1399)
PURPOSE: The objective of this study was to define whether survival of patients with extremity soft tissue sarcoma (STS), stratified for known risk factors, has improved over the last 20 years. PATIENTS AND METHODS: From January 1982 to December 2001, 1,706 patients with primary and recurrent STS of the extremities were treated at our institution and were prospectively followed. From this cohort, we selected 1,261 patients who underwent complete macroscopic resection and had one of the following histopathologies: fibrosarcoma, liposarcoma, leiomyosarcoma, malignant fibrous histiocytoma, or synovial sarcoma. Median follow-up was 55 months. Patient, tumor, and treatment factors were analyzed as prognostic factors. RESULTS: The 5-year disease-specific actuarial survival was 79% (78% for patients treated from 1982 to 1986, 79% for patients treated from 1986 to 1991, 79% for patients treated from 1992 to 1996, and 85% for patients treated from 1997 to 2001; P = not significant). For high-risk patients (high-grade, > 10 cm, deep tumors; n = 247), 5-year disease-specific survival was 51% (50% for patients treated from 1982 to 1986, 45% for patients treated from 1986 to 1991, 52% for patients treated from 1992 to 1996, and 61% for patients treated from 1997 to 2001; P = not significant). Tumor depth, size, grade, microscopic margin status, patient age, presentation status (primary tumor versus local recurrence), location (proximal versus distal), and certain histopathologic subtypes were significant prognostic factors for disease-specific survival on multivariate analysis; however, time period of treatment was not. CONCLUSION: Prognosis of patients with extremity STS, stratified for known risk factors, has not improved over the last 20 years, indicating that current therapy has reached the limits of efficacy. (+info)
Muscle force-length dynamics during level versus incline locomotion: a comparison of in vivo performance of two guinea fowl ankle extensors.
(40/1399)
For a terrestrial animal to move in the complex natural environment, the limb muscles must modulate force and work performance to meet changing mechanical requirements; however, it is not clear whether this is accomplished via a collective shift in function by all limb muscles, or a division of labor among limb muscles. Do muscles differ in their ability to modulate force-length contractile function to meet the mechanical demands of different locomotor tasks? We explore this question by examining the in vivo force-length performance of the guinea fowl Numida meleagris lateral gastrocnemius (LG) and digital flexor-IV (DF-IV), during level and incline locomotion. During level locomotion, the LG and DF-IV exhibit differing muscle fascicle strain patterns: the LG shortens by 10-15% while developing force, whereas the DF-IV undergoes a stretch-shorten cycle with large strain amplitudes and small net strains of 1-8%. Furthermore, the DF-IV operates at higher muscle stresses (92-130 kPa, compared to 23-39 kPa for LG) and possesses a longer tendon, which allows the DF-IV tendon to recover greater elastic energy than the LG tendon. During incline locomotion, these muscles contribute only one-third of the energy expected for their mass, with the DF-IV exhibiting high stride-to-stride variability in work output. While the stretch-shorten cycle of the DF-IV muscle may allow more economic force production, it also leads to large changes in work output with small changes in the relative timing of force and strain. Thus, while the primary determinants of LG work are net strain and mean force, the primary determinant of DF-IV work is the phase relationship between force and strain. Our results suggest that, in addition to influencing a muscle's mechanical performance during steady level locomotion, morphology also affects its capacity and mechanism for altering work output for different locomotor tasks. (+info)