- Email: [email protected]
Iatrogenic Interval Gangrene of the Thigh
Journal Pre-proof Iatrogenic interval gangrene of the thigh Flynn S, BA, Montoya M, BA, MBS, Bikkina R, Hammond BJ, Dardik H, MD, FACS, Bernik T, MD, FACS PII:
S0890-5096(19)30987-2
DOI:
https://doi.org/10.1016/j.avsg.2019.11.025
Reference:
AVSG 4788
To appear in:
Annals of Vascular Surgery
Received Date: 15 August 2019 Revised Date:
11 November 2019
Accepted Date: 11 November 2019
Please cite this article as: S F, M M, R B, BJ H, H D, T B, Iatrogenic interval gangrene of the thigh, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.11.025. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
Iatrogenic interval gangrene of the thigh
2 3
Flynn S, BA, Montoya M, BA, MBS, Bikkina R, Hammond BJ, Dardik H, MD, FACS,
4
Bernik T, MD, FACS
5
Department of Vascular Surgery- Englewood Hospital and Medical Center, Englewood NJ
6 7 8
Corresponding Author Contact Information:
9
Dr. Thomas Bernik, MD, FACS
10
Englewood Hospital and Medical Center
11
350 Engle Street, Englewood, NJ 07631
12
Email: [email protected]
13
Phone: 201-894-3689
14 15
Key Words: Gangrene, Collateral, Interval, Superficial femoral artery, Profunda femoris
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1
32
Iatrogenic interval gangrene of the thigh
33
Flynn S, BA, Montoya M, BA, MBS, Bikkina R, Hammond BJ, Dardik H, MD, FACS,
34
Bernik T, MD, FACS
35
Department of Vascular Surgery- Englewood Hospital and Medical Center, Englewood NJ
36 37
Interval gangrene of the thigh is an extremely rare complication in vascular surgery. Most cases
38
have reported interval gangrene of the calf as a consequence of a distal bypass procedure,1-6 with
39
little documentation of interval thigh gangrene occurring after endovascular intervention.7 The
40
present case suggests that in the process of placing multiple-level covered and bare metal stents
41
in the iliac, superficial femoral, and popliteal arteries, interval gangrene of the thigh must be
42
considered as a potential, albeit rare, complication. Preservation of pelvic and profunda femoris
43
flow to the thigh is imperative to prevent the development of interval tissue loss. This case
44
demonstrates the importance of maintaining profunda femoris circulation especially in patients
45
with significant vascular comorbidities. Patient consent was obtained for details of the case to be
46
used for publication.
47 48
CASE REPORT
49
An 85 year old female with diabetes mellitus and a history of multiple previous vascular
50
interventions in the lower extremities presented with a 20 X 10 cm gangrenous wound of the left
51
medial thigh and second toe gangrene. She had undergone extensive endovascular repair from
52
the iliac to the popliteal artery with covered stents. Angiography showed a normal aortoiliac
53
system with patency of the external iliac, superficial femoral and popliteal arteries. However,
54
the left profunda femoris artery had been excluded by the covered stents including branch vessels
55
that normally provide collateral flow to the profunda and popliteal systems (Figure 1A).
56
Atherectomy of the tibioperoneal trunk and proximal peroneal artery was performed as well as
57
balloon angioplasty of the posterior tibial, both with excellent results confirmed by
58
angiography. Following these procedures, extensive debridement of the thigh was performed
59
with placement of a vacuum assisted closure device. However, the medial thigh wound failed to
60
heal after weeks of intensive wound management, clearly due to compromised profunda and
61
pelvic circulatory systems. A right femoral to left profunda PTFE bypass was performed,
2
62
establishing excellent flow to the profunda (Figure 1B). The thigh wound subsequently healed
63
without complications.
64 65
DISCUSSION
66
With only a total of eleven cases reported in the literature (Table 1), interval gangrene is a rare
67
complication in vascular surgery. Two thirds of the reported cases terminated in amputation, a
68
fact that further illustrates the devastating nature of this complication and the attention that needs
69
to be paid to its etiology. Ten of these cases were reported after a bypass procedure, and only
70
one, similar to the present case, was reported after extensive stent placements. In each case
71
involving a bypass procedure, the author cites lack of flow from the branches originating from
72
the bypassed arterial segment as the likely cause for this complication.1-6 In our case, the prior
73
use of covered stents from the illiac to the popliteal artery prevented flow to the hypogastric and
74
the profunda femoris systems. Pua et al.7 described a similar case in which covered stents placed
75
in the SFA prevented collateral flow to the thigh, ultimately leading to thigh necrosis. Both of
76
these cases clearly show the potential of interval gangrene as a complication following multiple
77
covered stent placements in the critical areas that would prevent adequate flow to maintain tissue
78
viability. Clearly distal perfusion is not the only requirement for a successful outcome. Loss of
79
branch flow associated with covered stents may lead to significant tissue or limb loss and should
80
be avoided.
81 82
The use of covered stents is common in the treatment of lower limb ischemia with data
83
indicating higher rates of patency with covered stents.8-10 If extensive stenting is required,
84
additional consideration needs to be given to the type and location of the stents in order to avoid
85
potential loss of collateral flow to the thigh. With the expansion of multidisciplinary
86
interventionists, these considerations must be respectively emphasized in order to prevent
87
devastating ischemia in the thigh and knee areas.
88 89
CONCLUSION
90
Bypass and extensive stenting procedures are associated with risk for developing interval
91
gangrene of the thigh in the absence of collateral flow to this region. As endovascular techniques
92
continue to be emphasized, the prevalence of interval gangrene following stent placement may
3
93
increase, especially with current suggestions that covered stents may improve stent patency
94
rates.8-10 It is therefore essential that consideration be given to the potential for interval
95
gangrene, especially in patients with combined peripheral vascular disease and diabetes. This
96
includes a thorough analysis of the collateral networks of the thigh and upper leg.
97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123
4
124
FIGURE 1A
125 126
FIGURE 1A: Angiogram depicting covered stent in left iliofemoral and popliteal arterial
127
systems. Blockage of the profunda femoris at the origin prevented blood flow to the thigh and
128
knee areas resulting in ischemia and gangrene.
129 130 131 132 5
133
FIGURE 1B
134 135
FIGURE 1B: Following placement of bypass from the right femoral artery to the left profunda
136
femoris, reperfusion is noted on the thigh and knee, with visualization of the profunda system
137
(arrow) and branches.
138 139 140 141 142 143 144 145 146 6
147
TABLE 1 Case Ref # Age/Sex Year Procedure 1
2
148 149 150 151 152
1
2
Comorbidity
Gangrene Location
Outcome
NR
Thigh
Hip Disarticulation
Thigh
Hemipelvectomy
NR
Femoral-Popliteal 1979 Bypass
71/F
Axillodistal Superficial Femoral- Peripheral Artery 1987 Distal Peroneal Bypass Disease
DM, Hypertension Malleolar
AKA
3
2
69/F
Femoral-Distal Posterior Tibial 1987 Bypass
4
2
71/M
Popliteal-Anterior 1987 Tibial Vein Bypass
DM
Calf
AKA
5
2
69/M
Popliteal-Anterior 1987 Tibial Bypass
Rheumatoid Arthritis, Smoker
Calf
AKA
Hypertension
Genicular
AKA
6
3
53/M
Superficial FemoralPosterior Tibial 1991 Bypass
7
3
41/M
Femoral Dorsalis 1991 Pedis Bypass
None
Thigh
No amputation
8
4
80/F
Femoroperoneal 1993 Bypass
DM, COPD
Malleolar
AKA
9
5
42/M
1995 Femoral-Tibial Bypass Smoker
Thigh
No amputation
10
6
71/M
Superficial Femoral1997 Dorsalis Pedis Bypass DM, TPOD
Calf
No amputation
11
7
67/F
Superficial Femoral 2005 Stenting
DM
Thigh
No amputation
12
*
85/F
Superficial Femoral 2018 Stenting
DM, COPD
Thigh
No amputation
Table 1 summarizes cases of interval gangrene in literature. (NR: Not Reported; DM: Diabetes Mellitus; COPD: Chronic Obstructive Pulmonary Disease; AKA: Above Knee Amputation; TPOD: Tibioperoneal Occlusive Disease).
153 154 155 156 157 158
7
159
REFERENCES
160
1. Rudich M, Gutierrez IZ, Gage AA. Obturator foramen bypass in the management of infected
161
vascular prostheses. Am J of Surg. 1979; 137: 657–660.
162
2. Memsic L, Busuttil RW, Machleder H, Quinones-Baldrich W, Baker D, Moore W. Interval
163
Gangrene Occurring After Successful Lower-Extremity Revascularization. Arch Surg. 1987;
164
122: 1060–1063.
165
3. Dardik H, Pecoraro J, Wolodiger F, Kahn M, Ibrahim IM, Sussman B. Interval gangrene of
166
the lower extremity: A complication of vascular surgery. J Vasc Surg. 1991; 13: 412–415.
167
4. Nie AD, Yo T. Interval Gangrene After Femorodistal Bypass: Case Report. Vasc Endovasc
168
Surg. 1993; 27: 236–239.
169
5. Gentile AT, Porter JM. Interval Gangrene After Femoral Tibial Bypass Grafting. Perspect
170
Vasc Surg Endovasc Ther. 1995; 8: 76–81.
171
6. Gooden MA, Gentile AT, Demas CP, Berman SS, Mills JL. Salvage of femoropedal bypass
172
graft complicated by interval gangrene and vein graft blowout using a flow-through radial
173
forearm fasciocutaneous free flap. J Vasc Surg. 1997; 26: 711–714.
174
7. Pua BB, Muhs BE, Parikh MS, Lamparello PJ. Interval gangrene complicating superficial
175
femoral artery stent placement. J Vasc Surg. 2005; 42: 564–566.
176
8. Lammer J, Zeller T, Hausegger KA, et al. Heparin-Bonded Covered Stents Versus Bare-Metal
177
Stents for Complex Femoropopliteal Artery Lesions. J Am Coll Cardiol. 2013; 62: 1320-1327.
178
9. Lammer J, Zeller T, Hausegger KA, et al. Sustained Benefit at 2 Years for Covered Stents
179
Versus Bare-Metal Stents in Long SFA Lesions: The VIASTAR Trial. Cardiovasc Intervent
180
Radiol. 2015; 38: 25-32.
181
10. Matos J, Bechara CF, Barshes NR, et al. Comparison of Outcomes Between Bare Metal and
182
Covered Nitinol Stents in the Treatment of TASC C and D Superficial Femoral Artery (SFA)
183
and Popliteal Lesions. J Vasc Surg. 2013; 57: 63S-64S.
184
11. He C, Yang J-G, Li Y-M, et al. Comparison of lower extremity atherosclerosis in diabetic
185
and non-diabetic patients using multidetector computed tomography. BMC Cardiovasc Disord.
186
2014; 14: 125.
187
12. Sawicki PT, Kaiser S, Heinemann L, Frenzel H, Berger M. Prevalence of renal artery
188
stenosis in diabetes mellitus - an autopsy study. J Intern Med. 1991; 229(6): 489-492.
8
189
13. Shah B, Rockman CB, Guo Y, et al. Diabetes and Vascular Disease in Different Arterial
190
Territories. Diabetes Care. 2014; 37: 1636-1642.
191
14. Boinpally H, Howell RS, Mazzie J, Slone E, Woods JS, Gillette BM, et al. A Wolf in
192
Sheep’s Clothing: An Unusual Presentation of Diabetic Myonecrosis. Adv Skin Wound Care.
193
2018; 31: 394–398.
194
15. Creager MA, Paneni F, Beckman JA, Cosentino F. Diabetes and Vascular Disease:
195
Pathophysiology, Clinical Consequences, and Medical Therapy: Part I. Eur Heart J. 2013; 34:
196
2436–2443.
197 198
9
TABLE 1 Case Ref # Age/Sex Year Procedure 1
2
3
1
2
2
Comorbidity
Gangrene Location
Outcome
NR
Thigh
Hip Disarticulation
Thigh
Hemipelvectomy
NR
Femoral-Popliteal 1979 Bypass
71/F
Axillodistal Superficial Femoral- Peripheral Artery 1987 Distal Peroneal Bypass Disease
69/F
Femoral-Distal Posterior Tibial 1987 Bypass
DM, Hypertension Malleolar
AKA
DM
Calf
AKA
4
2
71/M
Popliteal-Anterior 1987 Tibial Vein Bypass
5
2
69/M
Popliteal-Anterior 1987 Tibial Bypass
Rheumatoid Arthritis, Smoker
Calf
AKA
53/M
Superficial FemoralPosterior Tibial 1991 Bypass
Hypertension
Genicular
AKA
None
Thigh
No amputation
DM, COPD
Malleolar
AKA
6
3
7
3
41/M
Femoral Dorsalis 1991 Pedis Bypass
8
4
80/F
Femoroperoneal 1993 Bypass
9
5
42/M
1995 Femoral-Tibial Bypass Smoker
Thigh
No amputation
Calf
No amputation
10
6
71/M
Superficial Femoral1997 Dorsalis Pedis Bypass DM, TPOD
11
7
67/F
Superficial Femoral 2005 Stenting
DM
Thigh
No amputation
12
*
85/F
Superficial Femoral 2018 Stenting
DM, COPD
Thigh
No amputation
Table 1 summarizes cases of interval gangrene in literature. (NR: Not Reported; DM: Diabetes Mellitus; COPD: Chronic Obstructive Pulmonary Disease; AKA: Above Knee Amputation; TPOD: Tibioperoneal Occlusive Disease).
S0890-5096(19)30987-2
DOI:
https://doi.org/10.1016/j.avsg.2019.11.025
Reference:
AVSG 4788
To appear in:
Annals of Vascular Surgery
Received Date: 15 August 2019 Revised Date:
11 November 2019
Accepted Date: 11 November 2019
Please cite this article as: S F, M M, R B, BJ H, H D, T B, Iatrogenic interval gangrene of the thigh, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2019.11.025. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier Inc.
1
Iatrogenic interval gangrene of the thigh
2 3
Flynn S, BA, Montoya M, BA, MBS, Bikkina R, Hammond BJ, Dardik H, MD, FACS,
4
Bernik T, MD, FACS
5
Department of Vascular Surgery- Englewood Hospital and Medical Center, Englewood NJ
6 7 8
Corresponding Author Contact Information:
9
Dr. Thomas Bernik, MD, FACS
10
Englewood Hospital and Medical Center
11
350 Engle Street, Englewood, NJ 07631
12
Email: [email protected]
13
Phone: 201-894-3689
14 15
Key Words: Gangrene, Collateral, Interval, Superficial femoral artery, Profunda femoris
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1
32
Iatrogenic interval gangrene of the thigh
33
Flynn S, BA, Montoya M, BA, MBS, Bikkina R, Hammond BJ, Dardik H, MD, FACS,
34
Bernik T, MD, FACS
35
Department of Vascular Surgery- Englewood Hospital and Medical Center, Englewood NJ
36 37
Interval gangrene of the thigh is an extremely rare complication in vascular surgery. Most cases
38
have reported interval gangrene of the calf as a consequence of a distal bypass procedure,1-6 with
39
little documentation of interval thigh gangrene occurring after endovascular intervention.7 The
40
present case suggests that in the process of placing multiple-level covered and bare metal stents
41
in the iliac, superficial femoral, and popliteal arteries, interval gangrene of the thigh must be
42
considered as a potential, albeit rare, complication. Preservation of pelvic and profunda femoris
43
flow to the thigh is imperative to prevent the development of interval tissue loss. This case
44
demonstrates the importance of maintaining profunda femoris circulation especially in patients
45
with significant vascular comorbidities. Patient consent was obtained for details of the case to be
46
used for publication.
47 48
CASE REPORT
49
An 85 year old female with diabetes mellitus and a history of multiple previous vascular
50
interventions in the lower extremities presented with a 20 X 10 cm gangrenous wound of the left
51
medial thigh and second toe gangrene. She had undergone extensive endovascular repair from
52
the iliac to the popliteal artery with covered stents. Angiography showed a normal aortoiliac
53
system with patency of the external iliac, superficial femoral and popliteal arteries. However,
54
the left profunda femoris artery had been excluded by the covered stents including branch vessels
55
that normally provide collateral flow to the profunda and popliteal systems (Figure 1A).
56
Atherectomy of the tibioperoneal trunk and proximal peroneal artery was performed as well as
57
balloon angioplasty of the posterior tibial, both with excellent results confirmed by
58
angiography. Following these procedures, extensive debridement of the thigh was performed
59
with placement of a vacuum assisted closure device. However, the medial thigh wound failed to
60
heal after weeks of intensive wound management, clearly due to compromised profunda and
61
pelvic circulatory systems. A right femoral to left profunda PTFE bypass was performed,
2
62
establishing excellent flow to the profunda (Figure 1B). The thigh wound subsequently healed
63
without complications.
64 65
DISCUSSION
66
With only a total of eleven cases reported in the literature (Table 1), interval gangrene is a rare
67
complication in vascular surgery. Two thirds of the reported cases terminated in amputation, a
68
fact that further illustrates the devastating nature of this complication and the attention that needs
69
to be paid to its etiology. Ten of these cases were reported after a bypass procedure, and only
70
one, similar to the present case, was reported after extensive stent placements. In each case
71
involving a bypass procedure, the author cites lack of flow from the branches originating from
72
the bypassed arterial segment as the likely cause for this complication.1-6 In our case, the prior
73
use of covered stents from the illiac to the popliteal artery prevented flow to the hypogastric and
74
the profunda femoris systems. Pua et al.7 described a similar case in which covered stents placed
75
in the SFA prevented collateral flow to the thigh, ultimately leading to thigh necrosis. Both of
76
these cases clearly show the potential of interval gangrene as a complication following multiple
77
covered stent placements in the critical areas that would prevent adequate flow to maintain tissue
78
viability. Clearly distal perfusion is not the only requirement for a successful outcome. Loss of
79
branch flow associated with covered stents may lead to significant tissue or limb loss and should
80
be avoided.
81 82
The use of covered stents is common in the treatment of lower limb ischemia with data
83
indicating higher rates of patency with covered stents.8-10 If extensive stenting is required,
84
additional consideration needs to be given to the type and location of the stents in order to avoid
85
potential loss of collateral flow to the thigh. With the expansion of multidisciplinary
86
interventionists, these considerations must be respectively emphasized in order to prevent
87
devastating ischemia in the thigh and knee areas.
88 89
CONCLUSION
90
Bypass and extensive stenting procedures are associated with risk for developing interval
91
gangrene of the thigh in the absence of collateral flow to this region. As endovascular techniques
92
continue to be emphasized, the prevalence of interval gangrene following stent placement may
3
93
increase, especially with current suggestions that covered stents may improve stent patency
94
rates.8-10 It is therefore essential that consideration be given to the potential for interval
95
gangrene, especially in patients with combined peripheral vascular disease and diabetes. This
96
includes a thorough analysis of the collateral networks of the thigh and upper leg.
97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123
4
124
FIGURE 1A
125 126
FIGURE 1A: Angiogram depicting covered stent in left iliofemoral and popliteal arterial
127
systems. Blockage of the profunda femoris at the origin prevented blood flow to the thigh and
128
knee areas resulting in ischemia and gangrene.
129 130 131 132 5
133
FIGURE 1B
134 135
FIGURE 1B: Following placement of bypass from the right femoral artery to the left profunda
136
femoris, reperfusion is noted on the thigh and knee, with visualization of the profunda system
137
(arrow) and branches.
138 139 140 141 142 143 144 145 146 6
147
TABLE 1 Case Ref # Age/Sex Year Procedure 1
2
148 149 150 151 152
1
2
Comorbidity
Gangrene Location
Outcome
NR
Thigh
Hip Disarticulation
Thigh
Hemipelvectomy
NR
Femoral-Popliteal 1979 Bypass
71/F
Axillodistal Superficial Femoral- Peripheral Artery 1987 Distal Peroneal Bypass Disease
DM, Hypertension Malleolar
AKA
3
2
69/F
Femoral-Distal Posterior Tibial 1987 Bypass
4
2
71/M
Popliteal-Anterior 1987 Tibial Vein Bypass
DM
Calf
AKA
5
2
69/M
Popliteal-Anterior 1987 Tibial Bypass
Rheumatoid Arthritis, Smoker
Calf
AKA
Hypertension
Genicular
AKA
6
3
53/M
Superficial FemoralPosterior Tibial 1991 Bypass
7
3
41/M
Femoral Dorsalis 1991 Pedis Bypass
None
Thigh
No amputation
8
4
80/F
Femoroperoneal 1993 Bypass
DM, COPD
Malleolar
AKA
9
5
42/M
1995 Femoral-Tibial Bypass Smoker
Thigh
No amputation
10
6
71/M
Superficial Femoral1997 Dorsalis Pedis Bypass DM, TPOD
Calf
No amputation
11
7
67/F
Superficial Femoral 2005 Stenting
DM
Thigh
No amputation
12
*
85/F
Superficial Femoral 2018 Stenting
DM, COPD
Thigh
No amputation
Table 1 summarizes cases of interval gangrene in literature. (NR: Not Reported; DM: Diabetes Mellitus; COPD: Chronic Obstructive Pulmonary Disease; AKA: Above Knee Amputation; TPOD: Tibioperoneal Occlusive Disease).
153 154 155 156 157 158
7
159
REFERENCES
160
1. Rudich M, Gutierrez IZ, Gage AA. Obturator foramen bypass in the management of infected
161
vascular prostheses. Am J of Surg. 1979; 137: 657–660.
162
2. Memsic L, Busuttil RW, Machleder H, Quinones-Baldrich W, Baker D, Moore W. Interval
163
Gangrene Occurring After Successful Lower-Extremity Revascularization. Arch Surg. 1987;
164
122: 1060–1063.
165
3. Dardik H, Pecoraro J, Wolodiger F, Kahn M, Ibrahim IM, Sussman B. Interval gangrene of
166
the lower extremity: A complication of vascular surgery. J Vasc Surg. 1991; 13: 412–415.
167
4. Nie AD, Yo T. Interval Gangrene After Femorodistal Bypass: Case Report. Vasc Endovasc
168
Surg. 1993; 27: 236–239.
169
5. Gentile AT, Porter JM. Interval Gangrene After Femoral Tibial Bypass Grafting. Perspect
170
Vasc Surg Endovasc Ther. 1995; 8: 76–81.
171
6. Gooden MA, Gentile AT, Demas CP, Berman SS, Mills JL. Salvage of femoropedal bypass
172
graft complicated by interval gangrene and vein graft blowout using a flow-through radial
173
forearm fasciocutaneous free flap. J Vasc Surg. 1997; 26: 711–714.
174
7. Pua BB, Muhs BE, Parikh MS, Lamparello PJ. Interval gangrene complicating superficial
175
femoral artery stent placement. J Vasc Surg. 2005; 42: 564–566.
176
8. Lammer J, Zeller T, Hausegger KA, et al. Heparin-Bonded Covered Stents Versus Bare-Metal
177
Stents for Complex Femoropopliteal Artery Lesions. J Am Coll Cardiol. 2013; 62: 1320-1327.
178
9. Lammer J, Zeller T, Hausegger KA, et al. Sustained Benefit at 2 Years for Covered Stents
179
Versus Bare-Metal Stents in Long SFA Lesions: The VIASTAR Trial. Cardiovasc Intervent
180
Radiol. 2015; 38: 25-32.
181
10. Matos J, Bechara CF, Barshes NR, et al. Comparison of Outcomes Between Bare Metal and
182
Covered Nitinol Stents in the Treatment of TASC C and D Superficial Femoral Artery (SFA)
183
and Popliteal Lesions. J Vasc Surg. 2013; 57: 63S-64S.
184
11. He C, Yang J-G, Li Y-M, et al. Comparison of lower extremity atherosclerosis in diabetic
185
and non-diabetic patients using multidetector computed tomography. BMC Cardiovasc Disord.
186
2014; 14: 125.
187
12. Sawicki PT, Kaiser S, Heinemann L, Frenzel H, Berger M. Prevalence of renal artery
188
stenosis in diabetes mellitus - an autopsy study. J Intern Med. 1991; 229(6): 489-492.
8
189
13. Shah B, Rockman CB, Guo Y, et al. Diabetes and Vascular Disease in Different Arterial
190
Territories. Diabetes Care. 2014; 37: 1636-1642.
191
14. Boinpally H, Howell RS, Mazzie J, Slone E, Woods JS, Gillette BM, et al. A Wolf in
192
Sheep’s Clothing: An Unusual Presentation of Diabetic Myonecrosis. Adv Skin Wound Care.
193
2018; 31: 394–398.
194
15. Creager MA, Paneni F, Beckman JA, Cosentino F. Diabetes and Vascular Disease:
195
Pathophysiology, Clinical Consequences, and Medical Therapy: Part I. Eur Heart J. 2013; 34:
196
2436–2443.
197 198
9
TABLE 1 Case Ref # Age/Sex Year Procedure 1
2
3
1
2
2
Comorbidity
Gangrene Location
Outcome
NR
Thigh
Hip Disarticulation
Thigh
Hemipelvectomy
NR
Femoral-Popliteal 1979 Bypass
71/F
Axillodistal Superficial Femoral- Peripheral Artery 1987 Distal Peroneal Bypass Disease
69/F
Femoral-Distal Posterior Tibial 1987 Bypass
DM, Hypertension Malleolar
AKA
DM
Calf
AKA
4
2
71/M
Popliteal-Anterior 1987 Tibial Vein Bypass
5
2
69/M
Popliteal-Anterior 1987 Tibial Bypass
Rheumatoid Arthritis, Smoker
Calf
AKA
53/M
Superficial FemoralPosterior Tibial 1991 Bypass
Hypertension
Genicular
AKA
None
Thigh
No amputation
DM, COPD
Malleolar
AKA
6
3
7
3
41/M
Femoral Dorsalis 1991 Pedis Bypass
8
4
80/F
Femoroperoneal 1993 Bypass
9
5
42/M
1995 Femoral-Tibial Bypass Smoker
Thigh
No amputation
Calf
No amputation
10
6
71/M
Superficial Femoral1997 Dorsalis Pedis Bypass DM, TPOD
11
7
67/F
Superficial Femoral 2005 Stenting
DM
Thigh
No amputation
12
*
85/F
Superficial Femoral 2018 Stenting
DM, COPD
Thigh
No amputation
Table 1 summarizes cases of interval gangrene in literature. (NR: Not Reported; DM: Diabetes Mellitus; COPD: Chronic Obstructive Pulmonary Disease; AKA: Above Knee Amputation; TPOD: Tibioperoneal Occlusive Disease).