Postreconstructive outcomes were compared in diabetic patients with Charcot neuroarthropathy (CN) who had peripheral arterial disease (PAD) diagnosed with angiography versus patients who were ...diagnosed clinically. A retrospective review was performed of patients with diabetic CN requiring reconstruction secondary to ulceration and/or acute infection. Of the 284 patients in the CN osseous reconstruction cohort, after accounting for exclusion criteria, 59 (20.8%) patients with PAD were included in the analyses. Forty (67.8%) of these 59 patients were diagnosed with PAD clinically and 19 (32.2%) were diagnosed with the use of angiography. Bivariate analysis was used to compare outcomes between those diagnosed with PAD via angiography versus those diagnosed clinically for the following postreconstruction outcomes: wound healing, delayed healing, surgical site infection, pin tract infection, osteomyelitis, dehiscence, transfer ulcer, new site of Charcot collapse, contralateral Charcot event, nonunion, major lower extremity amputation, and return to ambulation. Bivariate analysis found return to ambulation postreconstruction (p = .0054) to be the only statistically significant factor. There was a trend toward significance for major lower extremity amputation, with higher rates of amputation in the clinically diagnosed PAD arm. Return to ambulation indicates improved functional outcomes. The main goal of limb salvage should be focused on improving the patient's functional performance. With significantly faster rates of return to ambulation and a trend toward decreased rates of major amputation, angiography was found to be a better assessor of PAD than clinical evaluations.
We studied endothelial-mediated microvascular blood flow in neuropathic diabetic patients to determine the association between endothelial regulation of the microcirculation and the expression of ...endothelial constitutive nitric oxide synthetase (ecNOS) in the skin. Vasodilation on the dorsal foot in response to heating and iontophoresis of acetylcholine (endothelium-dependent) and sodium nitroprusside (endothelium-independent) were measured using single-point laser Doppler and laser Doppler imaging in diabetic patients with neuropathy (DN), with neuropathy and vascular disease (DI), with Charcot arthropathy (DA), and without complications (D), and in healthy control subjects (C). The response to heat was reduced in the DN (321 21-629 percentage of increase over the baseline, median interquartile range) and DI (225 122-470) groups but was preserved in the DA (895 359-1,229), D (699 466-1,029), and C (810 440-1,064, P < 0.0001) groups. The endothelial-mediated response to acetylcholine was reduced in the DN (17 11-25), DA (22 2-34), and DI (13 2-30) groups compared with the D (47 24-58) and C (44 31-70, P < 0.001) groups. The non-endothelial-mediated response to sodium nitroprusside was also reduced in the DI (4 0-18), DN (17 9-26), and DA (21 11-31) groups compared with the D (37 19-41) and C (44 26-67, P < 0.0001) groups. There was a significant reduction in vasodilation in the DI group compared with all other groups (P < 0.0001). Full thickness skin biopsies from the dorsum of the foot of 15 DN, 10 DI, and 11 C study subjects were immunostained with antiserum to human ecNOS, the functional endothelial marker GLUT1, and the anatomical endothelial marker von Willebrand factor. The staining intensity of ecNOS was reduced in both diabetic groups. No differences were found among the three groups in the staining intensity of von Willebrand factor and GLUT1. We conclude that the endothelium-dependent and endothelium-independent vasodilations are impaired in diabetic patients predisposed to foot ulceration and that neuropathy is the main factor associated with this abnormality. Reduced expression of ecNOS may be a major contributing factor for endothelial dysfunction. These data provide support for a close association of neuropathy and microcirculation in the pathogenesis of foot ulceration.
During microanastomosis, the recipient artery must be controlled both proximally and distally, so that the donor flap artery may be anastomosed. Bulldog vascular clamps are often used; however, these ...clamps may fail to occlude heavily calcified vessels characteristic of diabetes and end-stage renal disease. Alternative clamps may need to be utilized, with the attendant risk of vessel injury. Herein, we present a case of free flap necrosis secondary to vascular clamp-mediated periansastomotic stenosis of a calcified free flap recipient artery. In this case, a 74-year-old diabetic male underwent anterolateral thigh free flap reconstruction for a left medial foot wound. The recipient's dorsalis pedis artery was noted to be heavily calcified intraoperatively and Bulldog clamps were unable to gain proximal and distal control, requiring the use of small-angled DeBakey vascular clamps. Ischemic flap changes were noted on postoperative day four. Subsequent angiogram demonstrated severe stenosis at the perianastomotic sites of the dorsalis pedis where the DeBakey clamps were placed for control. The arterial lesions were treated with balloon angioplasty and the patient underwent multiple debridements and placement of a split-thickness skin graft over the wound. At the six-month follow up, the wound achieved complete healing with insetting of the skin graft. In certain cases, the use of DeBakey or Satinsky clamps for arterial control in microsurgery may predispose the artery to intimal injury, causing stenosis that should be recognized early so that arteriography may be performed expeditiously. In this study, alternative methods of vascular control are described.
INTRODUCTIONTissue ischemia resulting from arterial insufficiency is a major factor affecting lower extremity wound healing in patients with peripheral arterial disease (PAD). Accelerated wound ...closure with split-thickness skin grafting (STSG) provides a durable barrier to infection and can prevent limb loss. Published STSG outcomes data are minimal in the post endovascular intervention population. OBJECTIVEIn this study, the authors examine factors predictive of STSG healing in patients with PAD following vascular intervention, including the effect of non-inline flow via arterial-arterial and non-arterial collateralization. MATERIALS AND METHODSPatients with PAD and wounds of the foot and ankle who underwent STSG between January 2014 and December 2016 were retrospectively reviewed. All patients received angiographic evaluation and endovascular or open revascularization where necessary. Effects of extremity revascularizations, STSG percent take, and amputation rate were evaluated. RESULTSThirty-five patients with 47 wounds underwent STSG. There were 21 men and 14 women with a mean age of 64 ± 13 years. Revascularization was required in 23 patients (25 extremities) before STSG, with balloon angioplasty for tibial artery lesions as the most common revascularization. Patent pedal arch was present in 8 patients; 35 patients had an absent or incomplete pedal arch. Patients with a fully patent pedal arch healed at a significantly higher rate than those with an absent or incomplete pedal arch at 1 month (62.5% vs. 17.1%, P ⟨ .05). At 90-day follow-up, 9 of 35 (25.7%) patients with 9 of 47 (19.1%) wounds were lost to follow-up, leaving 18 of 38 (47.37%) wounds healed and 20 (52.63%) still open. Ultimately, 36 of 47 (76.60%) wounds healed and 6 major amputations in 6 patients were required at a mean 502 ± 342 days follow-up. CONCLUSIONSThese results suggest the importance of arterial-arterial connections such as the pedal arch to the healing potential of foot and ankle wounds after STSG in this high-risk patient population.
We report the 44-year follow-up of a 9-year-old girl who underwent a saphenous vein interposition graft in 1964 after suffering extensive pelvic trauma with complete disruption of the right common ...femoral artery. The patient recovered from this injury and experienced no disability or pain until 2008, when she suddenly developed numbness in the right leg. Evaluation at that time showed a new occlusion of the saphenous vein graft, and she underwent uneventful repeat revascularization with autogenous vein. To our knowledge, this 44-year patency is the longest reported for a saphenous vein graft.
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