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Heel Wounds Predict Poor Outcomes After Infrapopliteal Revascularization
Journal of Vascular Surgery
Abstracts
e3
Volume 65, Number 3
Heel Wounds Predict Poor Outcomes After Infrapopliteal Revascularization Abhisekh Mohapatra, MD, Jon C. Henry, MD, Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD, Steven A. Leers, MD, Aureline Boitet, MD, Michael J. Singh, MD, Eric S. Hager MD. University of Pittsburgh Medical Center, Pittsburgh, PA Objective: Ischemic heel ulcerations are generally thought to carry a poor prognosis. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival than patients with forefoot wounds. Methods: Retrospective chart review was performed of patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes, then analyzed by initial wound classification. The primary outcome was major amputation or death. Results: There were 398 limbs that underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P ¼ .02). Heel wounds represented 12.1% of the total, with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P ¼ .94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (P ¼ .03) and renal insufficiency (P ¼ .004); 36.9% of wounds healed within 1 year, with no difference by wound location (P ¼ .30). Endovascular treatment was associated with improved healing of forefoot wounds (P ¼ .02) but not of heel wounds (P ¼ .14). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P ¼ .81) or treatment type (P ¼ .33). Three-year major amputation-free survival (Fig) was 43.8% with a forefoot wound and 20.8% with a heel wound (P ¼ .03). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of major amputation or death; however, there was significant interaction such that bypass improved outcomes in patients with forefoot wounds (hazard ratio, 1.97; P < .001) but not in those with heel wounds (hazard ratio, 0.79; P ¼ .53). Conclusions: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to lower amputation-free survival despite equivalent wound healing and regardless of treatment modality.
Background: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of poor tibial runoff on the patient-centered outcomes following tibial endovascular intervention. Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford class 4 and 5) were identified. Angiograms were reviewed in all cases to assess tibial runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, less than half the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1 to 10). Two runoff score groups were identified: <7 and >7. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia; 94% had hypertension, 70% had diabetes mellitus, 63% had hyperlipidemia, and 33% had chronic renal insufficiency (47% of these on hemodialysis). Technical success was 99% with a mean of two vessels treated per patient and a mean pedal runoff score of 6. Overall MALE was equivalent at 90 days after the procedure. At 5 years, vessels with compromised runoff (scores $7) had significantly lower ulcer healing and a lower limb salvage rate. Patients with poor runoff had significantly lower clinical efficacy, amputationfree survival, and MALE at 5 years (Table).
Table. Outcomes Runoff score <7
Runoff score $7
No. of limbs at risk
600
534
d
High-risk PIII score
18%
30%a
.01
P value
Mortality
1%
1%
NS
Morbidity
3%
5%b
.04
Ulcer healing without amputation, %
73 6 4
25 6 3
.01
5-year clinical efficacy, %, mean 6 SEM
48 6 4
20 6 8a
.01
5-year amputation-free survival, %, mean 6 SEM
45 6 3
17 6 9a
.01
5-year MALE, %, mean 6 SEM
50 6 5
11 6 6a
.01
MALE, Major adverse limb events; NS, not significant; PIII, Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III); SEM, standard error of the mean. a P < .01 compared with runoff score <7. b P < .05 compared with runoff score <7.
Fig. Amputation-free survival by wound location.
Author Disclosures: A. Mohapatra: None; J. C. Henry: None; E. D. Avgerinos: None; R. A. Chaer: None; S. A. Leers: None; A. Boitet: None; M. J. Singh: None; E. S. Hager: None.
Outcomes of Tibial Endovascular Interventions in Patients with Poor Pedal Runoff Hallie E. Baer-Bositis, MD, Taylor D. Hicks, MD, Georges M. Haider, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Maureen K. Sheehan, MD, Mark G. Davies MD, PhD, MBA. University of Texas Health Science Center-San Antonio, San Antonio, TX
Conclusions: Pedal runoff score can easily identify those patients who will not achieve ulcer healing and limb salvage after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions. Author Disclosures: H. E. Baer-Bositis: None; T. D. Hicks: None; G. M. Haider: None; L. L. Pounds: None; M. J. Sideman: None; M. K. Sheehan: None; M. G. Davies: None.
A Multi-Institutional Experience in Vascular Ehlers-Danlos Syndrome Sherene Shalhub, MD, MPH,1 Kelli Hicks, BS,1 Karen Woo, MD,2 Dawn Coleman, MD,3 Frank Davis, MD,3 Giovanni De Caridi, MD, PhD,4 K. Nicole Weaver, MD,5 Erin Miller, MS, CGC,6 Marc Schermerhorn, MD,7 Katie Shean, MD,7 Gustavo Oderich, MD,8 Mauricio Ribiero, MD, PhD,8 Cole Nishikawa, MD,9 Kristofer M. Charlton-Ouw, MD,10
Abstracts
e3
Volume 65, Number 3
Heel Wounds Predict Poor Outcomes After Infrapopliteal Revascularization Abhisekh Mohapatra, MD, Jon C. Henry, MD, Efthymios D. Avgerinos, MD, Rabih A. Chaer, MD, Steven A. Leers, MD, Aureline Boitet, MD, Michael J. Singh, MD, Eric S. Hager MD. University of Pittsburgh Medical Center, Pittsburgh, PA Objective: Ischemic heel ulcerations are generally thought to carry a poor prognosis. We hypothesized that patients undergoing infrapopliteal revascularization for heel wounds, either bypass or endovascular intervention, would have lower wound healing rates and amputation-free survival than patients with forefoot wounds. Methods: Retrospective chart review was performed of patients who presented between 2006 and 2013 to our institution with ischemic foot wounds and infrapopliteal arterial disease and underwent either pedal bypass or endovascular tibial artery intervention. Data were collected on patient demographics, comorbidities, wound characteristics, procedural details, and postoperative outcomes, then analyzed by initial wound classification. The primary outcome was major amputation or death. Results: There were 398 limbs that underwent treatment for foot wounds; accurate wound data were available in 380 cases. There were 101 bypasses and 279 endovascular interventions, with mean follow-up of 24.6 and 19.9 months, respectively (P ¼ .02). Heel wounds represented 12.1% of the total, with the remainder being forefoot wounds; there was no difference in treatment modality by wound type (P ¼ .94). Of 46 heel wounds, 5 (10.9%) had clinical or radiographic evidence of calcaneal osteomyelitis. Patients with heel wounds were more likely to have diabetes mellitus (P ¼ .03) and renal insufficiency (P ¼ .004); 36.9% of wounds healed within 1 year, with no difference by wound location (P ¼ .30). Endovascular treatment was associated with improved healing of forefoot wounds (P ¼ .02) but not of heel wounds (P ¼ .14). Major amputation rate at 1 year was 17.8%, with no difference by wound location (P ¼ .81) or treatment type (P ¼ .33). Three-year major amputation-free survival (Fig) was 43.8% with a forefoot wound and 20.8% with a heel wound (P ¼ .03). In a multivariate analysis, heel wounds and endovascular intervention were both predictors of major amputation or death; however, there was significant interaction such that bypass improved outcomes in patients with forefoot wounds (hazard ratio, 1.97; P < .001) but not in those with heel wounds (hazard ratio, 0.79; P ¼ .53). Conclusions: Patients presenting with heel ulceration who undergo infrapopliteal revascularization are prone to lower amputation-free survival despite equivalent wound healing and regardless of treatment modality.
Background: Tibial interventions for critical limb ischemia are now commonplace. The aim of this study was to examine the impact of poor tibial runoff on the patient-centered outcomes following tibial endovascular intervention. Methods: A database of patients undergoing lower extremity endovascular interventions between 2006 and 2016 was retrospectively queried. Patients with critical ischemia (Rutherford class 4 and 5) were identified. Angiograms were reviewed in all cases to assess tibial runoff. Each dorsalis pedis, lateral plantar, and medial plantar artery was assigned a score according to the reporting standards of the Society for Vascular Surgery (0, no stenosis >20%; 1, 21%-49% stenosis; 2, 50%-99% stenosis; 2.5, less than half the vessel length occluded; 3, more than half the vessel length occluded). A foot score (dorsalis pedis + medial plantar + lateral plantar + 1) was calculated for each foot (1 to 10). Two runoff score groups were identified: <7 and >7. Patient-oriented outcomes of clinical efficacy (absence of recurrent symptoms, maintenance of ambulation, and absence of major amputation), amputation-free survival (survival without major amputation), and freedom from major adverse limb events (MALE; above-ankle amputation of the index limb) or major reintervention (new bypass graft, jump/interposition graft revision) were evaluated. Results: There were 1134 patients (56% male; average age, 59 years) who underwent tibial intervention for critical ischemia; 94% had hypertension, 70% had diabetes mellitus, 63% had hyperlipidemia, and 33% had chronic renal insufficiency (47% of these on hemodialysis). Technical success was 99% with a mean of two vessels treated per patient and a mean pedal runoff score of 6. Overall MALE was equivalent at 90 days after the procedure. At 5 years, vessels with compromised runoff (scores $7) had significantly lower ulcer healing and a lower limb salvage rate. Patients with poor runoff had significantly lower clinical efficacy, amputationfree survival, and MALE at 5 years (Table).
Table. Outcomes Runoff score <7
Runoff score $7
No. of limbs at risk
600
534
d
High-risk PIII score
18%
30%a
.01
P value
Mortality
1%
1%
NS
Morbidity
3%
5%b
.04
Ulcer healing without amputation, %
73 6 4
25 6 3
.01
5-year clinical efficacy, %, mean 6 SEM
48 6 4
20 6 8a
.01
5-year amputation-free survival, %, mean 6 SEM
45 6 3
17 6 9a
.01
5-year MALE, %, mean 6 SEM
50 6 5
11 6 6a
.01
MALE, Major adverse limb events; NS, not significant; PIII, Project of Ex-Vivo vein graft Engineering via Transfection III (PREVENT III); SEM, standard error of the mean. a P < .01 compared with runoff score <7. b P < .05 compared with runoff score <7.
Fig. Amputation-free survival by wound location.
Author Disclosures: A. Mohapatra: None; J. C. Henry: None; E. D. Avgerinos: None; R. A. Chaer: None; S. A. Leers: None; A. Boitet: None; M. J. Singh: None; E. S. Hager: None.
Outcomes of Tibial Endovascular Interventions in Patients with Poor Pedal Runoff Hallie E. Baer-Bositis, MD, Taylor D. Hicks, MD, Georges M. Haider, MD, Lori L. Pounds, MD, Matthew J. Sideman, MD, Maureen K. Sheehan, MD, Mark G. Davies MD, PhD, MBA. University of Texas Health Science Center-San Antonio, San Antonio, TX
Conclusions: Pedal runoff score can easily identify those patients who will not achieve ulcer healing and limb salvage after tibial intervention. Defining such subgroups will allow stratification of the patients and appropriate application of interventions. Author Disclosures: H. E. Baer-Bositis: None; T. D. Hicks: None; G. M. Haider: None; L. L. Pounds: None; M. J. Sideman: None; M. K. Sheehan: None; M. G. Davies: None.
A Multi-Institutional Experience in Vascular Ehlers-Danlos Syndrome Sherene Shalhub, MD, MPH,1 Kelli Hicks, BS,1 Karen Woo, MD,2 Dawn Coleman, MD,3 Frank Davis, MD,3 Giovanni De Caridi, MD, PhD,4 K. Nicole Weaver, MD,5 Erin Miller, MS, CGC,6 Marc Schermerhorn, MD,7 Katie Shean, MD,7 Gustavo Oderich, MD,8 Mauricio Ribiero, MD, PhD,8 Cole Nishikawa, MD,9 Kristofer M. Charlton-Ouw, MD,10