Society For Clinical Vascular Surgery

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Minor Foot Amputations and Debridements Should Not Be Delayed in Patients Undergoing Revascularization for Critical Limb Ischemia
Derek P. de Grijs, MD, James H. Mehaffey, MD, William P. Robinson, MD.
University of Virginia, Charlottesville, VA, USA.

Objectives: Many patients requiring revascularization for critical limb ischemia present with tissue loss, ultimately requiring surgical resection. Implications of the timing of tissue resection remain ill-defined. It is the goal of this study to determine if the timing of tissue resection has any association with alterations in outcomes in these patients.
Methods:  A database (ACS-NSQIP) of patients undergoing both open and endovascular lower extremity revascularizations between 2011 and 2015 was retrospectively queried. Patients with critical limb ischemia were identified for inclusion. Patient demographic factors were recorded. Patient outcomes were evaluated, including major adverse cardiac events (MACE), major adverse limb events (MALE), and length of stay (LOS). Patients were grouped as either having undergone revascularization alone, having undergone revascularization with concurrent tissue resection (same anesthesia), or having undergone revascularization and reoperation with subsequent tissue resection (different anesthesia, same hospitalization). Included tissue resections ranged from transmetatarsal amputations to local tissue debridements. Multivariate logistic regression was then used to determine risk-adjusted effects of tissue resection/debridement on outcomes.
Results: Over the course of the study period, 11,785 lower extremity revascularization procedures were identified. Of these, 823 (7.98%) underwent concurrent tissue resection, and 539 (4.57%) underwent subsequent tissue resection. There was no difference in MACE(4.9% revascularization alone vs 5.6% concurrent resection vs 3.9% reoperation for resection, p=0.366) or MALE (10.4% revascularization alone, 10.3% concurrent resection, 12.6% reoperation for resection, p=0.262). Length of stay (LOS, 5.7 days revascularization alone vs 7.7 days concurrent resection vs 8.9 days reoperation for resection, p<0.0001) was longer in patients who underwent any form of tissue resection. Similarly, wound infection was highest in the group undergoing reoperation for resection (1.5% revascularization alone vs 1.2% concurrent resection vs 8.9% reoperation for resection, p<0.0001). After risk adjustment with multivariate logistic regression, timing of resection did not independently impact MACE, MALE or readmission, however, concurrent resection increased LOS (1.0 days, p<0.0001) while reoperation for resection increased LOS (2.3 days, p<0.0001).
Conclusions: Wound debridement and minor amputations can safely be done concurrently in patients undergoing revascularization in patients presenting with critical limb ischemia. Delay of tissue resection/debridement is associated with increased rates of wound infection and prolonged length of hospital stay. In light of these findings, tissue resection should not be delayed for patients undergoing revascularization for critical limb ischemia.

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