Predictive Factors for Limb Salvage and Foot Ulcer Recurrence in Patients with Chronic Limb-Threatening Ischemia After Multidisciplinary Team Treatment: A 6-Year Japanese Single-Center Study

Fujii, Miki; Yamada, Ai; Yamawaki, Kohei; Tsuda, S.; Miyamoto, Naokazu; Gan, Kunio; Terashi, Hiroto

doi:10.1177/15347346211041429

Cited by 7 publications

(18 citation statements)

References 36 publications

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“…Post-procedural PAT has been linked to limb salvage, as severity of the wound has been linked to limb loss despite revascularization. 16,25 When the wound is severe, to have any hope of salvage, the post-procedure perfusion must be essentially completely normal. It is possible that post-procedural PAT may be used as a marker of success, need for further intervention, or failure, and considered in conjunction with wound severity and response to revascularization and might dictate pursuing further revascularization efforts or accepting the necessity for higher level limb amputation.…”

Section: Discussionmentioning

confidence: 99%

“…[12][13][14] Given the increased burden and risk, there has been growing consensus that multidisciplinary teams improve outcomes. 15,16 However, the success or failure of management depends on what outcome is considered of primary importance. Freedom from amputation or survival might be regarded as technical success, but if the patient is lacking in independence or has major complications the interpretation of "success" becomes subjective.…”

Section: Introductionmentioning

confidence: 99%

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Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review

Cuschieri

Rao

Lara

et al. 2023

Journal for Vascular Ultrasound

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Introduction: The global burden of peripheral arterial disease and related critical limb ischemia has been increasing, and with it an increased incidence of limb loss and mortality. Multidisciplinary teams appear to have a beneficial impact on managing these complex patients, but measuring success depends on the outcome chosen. Determining the risk/benefit of intervention can be difficult, and there has been increasing emphasis on using frailty measures to predict the likelihood of morbidity and mortality after vascular interventions. Methods: We performed a retrospective review of patients referred to a multidisciplinary team over a 5-year period who underwent intervention. Data included the modified Frailty Index (mFI), Society for Vascular Surgery (SVS) WIfI wound score (0-2 vs 3), and pedal acceleration time (PAT) post-procedure. Outcomes analyzed were 1-year amputation-free survival (AFS-1), independence, and major complications. Results: There were 81 patients who underwent either open or endovascular revascularization. One-year amputation-free survival was positively correlated with post-procedure PAT (AFS-1 107.3 ± 25.5 vs non-AFS-1 174 ± 93; P = .025) and inversely related to wound score (SVS 3 AFS-1 5/17 [29%] vs SVS 0-2: 46/64 [72%]; P = .025). Independence was linked to wheelchair dependence prior to intervention with 6/16 (38%) patients patients spending more than 50% of their time in a wheelchair being independent versus 56/64 (88%) who were not wheelchair-dependent being independent ( P = .005). An mFI ≥6 was associated with increased incidence of major complications at 1 year (mFI ≥6 11/31 [35%] vs mFI <6 5/50 [10%]; P = .018). Conclusion: One-year amputation-free survival was impacted by post-procedural success as measured by PAT, but negatively impacted by severity of wound at presentation. An mFI ≥6 was associated with greater incidence of complications. These findings may impact decision-making in determining the relative risk/benefit of revascularization in CLI. Vascular technologists can have an important role in development of limb salvage teams.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review

Cuschieri

Rao

Lara

et al. 2023

Journal for Vascular Ultrasound

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“…The prognostic tests evaluated by the studies included: ABI in 9 studies 27,[30][31][32][33][34]36,39,40 ; ankle pressures in 10 studies 17,19,20,[23][24][25]27,32,33,35 ; TBI in 4 studies 27,[30][31][32] ; toe pressures in 9 studies 17,19,[23][24][25]27,32,35,37 ; TcPO 2 in 7 studies 29,30,32,33,37,38,41 ; skin perfusion pressure in 5 studies 16,18,34,35,42 ; continuous wave Doppler (pedal waveforms) in 2 studies 26,28 ; pedal pulses in 3 studies; 20,21,41 and Doppler ankle peak systolic velocity (threshold 35 cm/s) by 1 study.…”

Section: Evaluation Of Prognostic Testsmentioning

confidence: 99%

Performance of non‐invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review

Chuter

Schaper

Hinchliffe

et al. 2023

Diabetes Metabolism Res

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IntroductionThe presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes‐related foot ulcer (DFU). Determining performance of non‐invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non‐invasive bedside tests for PAD to predict DFU healing, healing post‐minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene.MethodsA database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non‐invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6‐month follow‐up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool.ResultsFrom 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle‐brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe‐brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post‐minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non‐healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10).ConclusionsPrognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post‐revascularisation bedside testing, and heterogenous subpopulations.

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Section: Introductionmentioning

confidence: 99%

“…4 Nonetheless, readmission rates for major amputation following these limb salvage interventions, and the associated financial burden among patients with CLTI remain substantially high. 5,6 In a multi-centered study by Iida and colleagues, 44% of patients with CLTI who initially underwent a limb salvage procedure (surgical or endovascular) were subsequently readmitted for additional procedures. 7 However, data regarding the readmission rates for major amputation stratified by surgical vs endovascular revascularization among CLTI patients remains sparse.…”

Section: Introductionmentioning

confidence: 99%

Factors Associated With Early Amputation in Patients With Chronic Limb Threatening Ischemia

Cho¹,

Tran

Bakhtiyar

et al. 2023

The American Surgeon™

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Introduction Despite advancements in revascularization procedures, early amputation (EA) among patients with chronic limb threatening ischemia (CLTI) are still common. The present study evaluated clinical outcomes of patients with CLTI and factors associated with EA. Methods The 2016-2019 Nationwide Readmission Database was queried to identify all adults (≥18 years) with CLTI of lower extremities undergoing limb salvage (LS) procedures. The primary outcome of the study was EA within 90 days of discharge. Secondary outcomes included infectious complication, length of stay (LOS), cumulative hospitalization cost and non-home discharge. Results Of 103,703 patients who initially underwent surgical or endovascular revascularization, 10,439 (10.1%) subsequently underwent major amputation within 90 days of discharge. Following risk adjustment, factors associated with higher odds of EA were male sex, low-income quartile, tissue loss due to ulceration or gangrene, end-stage renal disease, and diabetes. Compared to those undergoing open revascularization, patients with endovascular limb salvage had a higher likelihood of having early amputation (AOR 1.41, 95% CI 1.31-1.51). Patients undergoing EA had greater odd of infectious complication, incremental LOS, incremental cost and non-home discharge. Conclusions We identified several risk factors to be associated with EA in patients with CLTI. These findings may supplement the objective performance goals for limb-related outcomes and facilitate institutional limb salvage programs.

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Predictive Factors for Limb Salvage and Foot Ulcer Recurrence in Patients with Chronic Limb-Threatening Ischemia After Multidisciplinary Team Treatment: A 6-Year Japanese Single-Center Study

Cited by 7 publications

References 36 publications

Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review

Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review

Performance of non‐invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review

Factors Associated With Early Amputation in Patients With Chronic Limb Threatening Ischemia

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