IntroductionInfra-popliteal angioplasty continues to be widely performed with minimal evidence to guide practice. Endovascular device selection is contentious and there is even uncertainty over which artery to treat for optimum reperfusion. Direct reperfusion (DR) targets the artery supplying the ischaemic tissue. Indirect reperfusion (IR) targets an artery supplying collaterals to the ischaemic area. Our unit practice for the last eight years has been to attempt to open all tibial arteries at the time of angioplasty. When successful, this results in both direct and indirect; or combined reperfusion (CR). The aim was to review the outcomes of CR and compare them with DR or IR alone.MethodsAn eight year retrospective review from a single unit of all infra-popliteal angioplasties was undertaken. Wound healing, limb salvage, amputation-free and overall survival data as well as re-intervention rates were captured for all patients. Subgroup analysis for diabetics was undertaken. Kaplan Meier curves are presented for survival outcomes. All odds and hazard ratios (HR) and p values were corrected for bias from confounders using multivariate analysis.Results250 procedures were performed: 22 (9%) were CR; 115 (46%) DR and 113 (45%) IR. Amputation-free survival (HR 0.504, p = 0.039) and re-intervention and amputation-free survival (HR 0.414, p = 0.005) were significantly improved in patients undergoing CR compared to IR. Wound healing was similarly affected by reperfusion strategy (OR = 0.35, p = 0.047). Effects of CR over IR were similar when only diabetic patients were considered.ConclusionsCombined revascularisation can only be achieved in approximately 10% of patients. However, when successful, it results in significant improvements in wound healing and amputation-free survival over simple indirect reperfusion techniques.

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The authors present the case of an 87-year-old woman who developed a delayed onset of subcutaneous emphysema post-operatively. We discuss the causative factors - in this case, presumed injury to her hypo-pharynx during a reportedly uneventful endotracheal intubation, the investigations and the management of this rare complication.

A below knee amputation can be fashioned using a long posterior flap, or skew flap.Contemporaneous studies comparing the two are lacking. We review both short and long-term outcome of patients who have undergone BKA by either technique. This study suggests that rates of residual limb failure (requiring surgical revision) are equal between the two surgical methods used. However, functional outcomes in unilateral amputees using a prosthetic limb were better in those who had received a long posterior flap amputation. ConclusionsBoth techniques appear equivalent for rates of surgical residual limb failure. Functional outcomes may be better with the LPF.