The Utility of Advanced Lower-Extremity Duplex Using Pedal Acceleration Time in the Management of the Threatened Diabetic Foot.

BACKGROUND: Patients with diabetes and diffuse infrageniculate arterial disease who present with chronic limb-threatening ischemia require an exact anatomical plan for revascularization. Advanced pedal duplex can be used to define possible routes for revascularization. In addition, pedal acceleration time (PAT) can predict the success or failure of both medical and surgical interventions. METHODS: A retrospective review of patients who were referred to our group for unilateral limb-threatening ischemia with isolated infrageniculate disease was conducted. Pedal duplex and PAT at the base of the wound was performed before and 1 week after intervention. The primary endpoint was limb salvage at 1 year. Revascularization was defined as direct or indirect based on the angiosome concept. RESULTS: Fifty-four patients meeting inclusion criteria presented over a 5-year period (toe wound, n = 42; heel wound, n = 8; both, n = 4). At 1 year, 10 (18.5%) had required below-knee amputation, whereas the remainder had healed/improved. Limb salvage was predicted by absence of ongoing smoking, absence of dialysis, and postprocedural PAT (class I/II). Limb salvage did not correlate with direct versus indirect revascularization. CONCLUSIONS: Advanced lower-extremity duplex in conjunction with determining PAT at the area of concern is a useful technique for mapping the vasculature and identifying targets for revascularization in patients with diffuse infrageniculate disease. Target artery revascularization to the wound bed resulting in a PAT less than 180 msec is predictive of limb salvage, regardless of whether perfusion is direct or indirect.

Pedal Acceleration Time (PAT): A Novel Predictor of Limb Salvage.

BACKGROUND: In the setting of Peripheral Arterial Disease (PAD), pedal arch interrogation by ultrasound has not been well described. Patients with noncompressible vessels and/or open wounds of the foot may preclude the use of ankle-brachial indices, toe pressure measurements, or TcPO2, respectively. We propose that pedal artery interrogations with Pedal Acceleration Time (PAT) can be a predictor for limb salvage in patients with Chronic Limb-Threatening Ischemia (CLTI). METHODS: A retrospective review of a prospectively kept database was performed from 2018 to 2019. Patients with pending amputation due to severe infection (WIFI infection class 2 and 3) were excluded from the study. We identified 73 limbs with CLTI that fit the inclusion criteria. Data included WIFI classification, age, gender, cardiovascular risk factors, PAT, ABI, and TBI when reliable, were collected. PAT measurements were categorized into 4 classifications; 1 (40-120 msec), 2 (121-180 msec), 3 (181-224 msec), and 4 (Greater than 225 msec). Statistical analyses were performed. RESULTS: Seventy-three limbs with CLTI were included in our study. All patients underwent arterial revascularization with either percutaneous technique or arterial bypass. Limb salvage was achieved in 59 (81%) of the 73 limbs. All 59 limbs had a 2-classification improvement in their PAT following interventions. A total of 14 (19%) limbs without improvement in their PAT underwent above ankle level amputations. An improvement in PAT classes to class 1 or 2 is associated with limb salvage. CONCLUSIONS: Patients with noncompressible ankle pressures or nonobtainable toe pressures poses a challenge in the complete assessment of WIFI classification. Our group has shown that PAT can be used in the scoring system for severity of ischemia in conjunction with current WIFI classification. Our data suggests that limb salvage correlates with post procedure PAT in category 1 and 2. Therefore we propose that PAT be added as part of the WIFI classification.

Plantar Acceleration Time: A Novel Technique to Evaluate Arterial Flow to the Foot.

BACKGROUND: Arterial duplex ultrasound (DUS) and ankle-brachial indices (ABIs) are accepted methods for assessing lower limb arterial perfusion. However, in a significant number of diabetic patients, medial wall calcification often precludes an ABI measurement. Direct, noninvasive duplex imaging of the pedal arch in the setting of peripheral arterial disease (PAD) has not been well evaluated. Although plantar arch interrogation is new to vascular ultrasound, imaging the plantar arteries appears to be a reliable angiographic technique for critical limb ischemia. We sought to define the utility of Plantar Acceleration Time as a surrogate for ABIs. METHODS: Patients undergoing DUS including Plantar Acceleration Time for suspicion of PAD were retrospectively reviewed in a prospective database over a 1-year period. Two hundred fifty nondiabetic patients (499 limbs) with documented ABI were studied. Plantar Acceleration Time was calculated (milliseconds [msec]) in each limb in the lateral plantar artery. Statistical analyses were performed using linear regression and analysis of variance testing using Microsoft Excel database (version 2016; Microsoft Corp, Redmond, WA). Patients were then grouped into 4 classes based on their clinical symptoms and ABI. Plantar Acceleration Time was similarly grouped into 4 distinct classes and correlated with the clinical and ABI classes. RESULTS: Plantar Acceleration Time correlated significantly with ABI (P < 0.001). There were significant differences in Plantar Acceleration Times between each class based on ABI and clinical presentation (P < 0.001 for each): Class 1 Plantar Acceleration Times 89.9 ± 15.5 msec; Class 2, 152.3 ± 28.4 msec; Class 3, 209.8 ± 25.5 msec, and Class 4, 270.2 ± 35.3 msec. CONCLUSIONS: Plantar Acceleration Time demonstrates a high correlation with ABI in patients with compressible arteries. Based on our results we propose the following categories of Plantar Acceleration Time, which appear to correlate with both clinical and ABI findings. ABI of 0.90-1.3 correlates with a Plantar Acceleration Time of 0-120 msec, ABI of 0.69-0.89 correlates with a Plantar Acceleration Time of 121-180 msec, ABI of 0.40-0.68 correlates with a Plantar Acceleration Time of 181-224 msec, and an ABI of 0.00-0.39 correlates with a Plantar Acceleration Time of greater than 225 msec. Further studies are ongoing to confirm whether Plantar Acceleration Time may be a suitable substitute to ABIs in patients with noncompressible arteries that preclude meaningful ABIs and gives more information regarding targeted angiosome perfusion to the foot.

Estimating the risk of solid organ malignancy in patients undergoing routine computed tomography scans after endovascular aneurysm repair.

OBJECTIVE: Computed tomography (CT) scans are routinely used for graft surveillance in patients who have had endovascular repair (EVAR) of an abdominal aortic aneurysm. There is a growing concern for cancers associated with inadvertent use of CT scans. We report the estimated risk of radiation associated solid organ malignancy caused by routine surveillance CT after EVAR using the Biological Effects of Ionizing Radiation (BEIR VII) model created by U.S. National Institute of Science and National Research Council. METHODS: Our study estimated the excess relative risk (ERR) of a patient acquiring a solid organ malignancy secondary to radiation exposure from postoperative EVAR surveillance CT imaging. The radiation dose was calculated in sieverts (Sv). The ERR of solid organ malignancy, as given by the BEIR VII model, is = ß(s) D exp {γe*} (a/60)(η), where ß(s), γ, and η are data-derived parameters, e is age at exposure, and e* = (e-30)/10 for e < 30 and zero for e ≥ 30, a is attained age, and D is dose in sieverts. Dose-weighted ERRs were calculated to allow a comparison of malignancy risk when using a CT at all time points (model 1: 0, 1, 6, 12, and 18 months, 2, 3, and 4 years, and yearly thereafter) vs replacing the CT scan with two other models (model 2: CT once in 3 years) and (model 3: CT once in 5 years). The risk was stratified by age groups, sex, and use of two different radiation doses (15 or 31 mSv) per CT scan. Statistical analysis used the paired t test. RESULTS: There were significant differences between the ERR of solid organ malignancy in those patients who would undergo surveillance CTs at all time points vs those whose surveillance consisted of alternative modalities at some time points (P < .0001). The cumulative ERR of cancer from radiation was higher in those exposed to contrast-enhanced CT scans, younger people, with highest in the group aged 50 to 55 years (ERR, 0.43), and lowest in patients aged ≥ 80 years (ERR, 0.10). CONCLUSIONS: Patients undergoing routine CT scans for postoperative surveillance after EVAR are at risk for acquiring new solid organ malignancy due to radiation exposure. The risk is higher in young patients, women, and those exposed to multiple contrast-enhanced CT scans. Our analysis questions the need for routine surveillance CT scans after EVAR in the absence of endoleaks or a change in aneurysm morphology, based on an increased malignancy risk.

Varicose vein: current management.

The continued advancement of RFA and EVLS technology should provide for an increased safety profile and lasting efficacy for treating the major saphenous veins. The challenge lies in determining what type of patient comorbidities and anatomic variability result in higher recurrences after endothermal varicose vein treatment so that one can modify the choice of treatment appropriately. Further standardization of the FS technique may allow for its wider use in treating truncal varicosities. The powered phlebectomy system seems to be suited for isolated branch varicosities, but the sequelae of pain and ecchymosis may prevent it from becoming a mainstream treatment with stab phlebectomy and sclerotherapy as alternatives.

Period frequency of iliofemoral venous occlusive disease by Doppler ultrasound and corresponding treatment in a tertiary care facility.

BACKGROUND: Patients with iliofemoral deep venous thrombosis (DVT) are at highest risk for the postthrombotic morbidity including all aspects of the postthrombotic syndrome. Invasive therapies such as catheter-directed thrombolysis (CDT) and/or mechanical thrombectomy with or without angioplasty and stenting and in some cases open operative thrombectomy improves venous patency, venous valve function, and quality of life in patients with acute iliofemoral DVT. What is the current frequency of acute iliofemoral DVT and how aggressively is it being treated? We hypothesize that the 10-year period frequency of iliofemoral DVT among acute DVT cases is greater than previously reported. Further, we hypothesize that thrombus removal to treat acute iliofemoral DVT is little utilized in current practice. METHODS: Indiana University (IU) vascular laboratory records from January 1, 1998 to December 31, 2008 were searched by CPT code for venous Doppler ultrasound study (n=7240). A random sample based on the IU medical record number of lower extremity Doppler studies was then selected (n=1020) for retrospective chart review. Corresponding clinical information was gathered from the patients' electronic medical record. RESULTS: Acute DVT occurred in 6.8%, and chronic DVT in 8.8% of patients studied (25.7% inpatient, 61.7% female; median age, 56.0 years [range, 4-91 years, 1.1% less than 16 years]). History of previous DVT (33.3%) and cancer (30.4%) were the most common risk factors in patients with acute DVT. Iliofemoral DVT defined as having an iliac or common femoral vein component was identified in 49.3% of acute DVT and in 36.0% of chronic DVT. CDT was utilized in 14.3% and mechanical thrombectomy in 4.8% of acute iliofemoral DVT, and was never used with distal DVT. Warfarin anticoagulation+unfractionated heparin or low-molecular-weight heparin overlap was the most common treatment for acute iliofemoral DVT (100.0%). In 2008, the referral base of our laboratory increased significantly. Acute DVT occurred significantly less often during the 1-year period 2008 (5.3%) than the 10-year period 1998-2007 (7.6%), but iliofemoral+common femoral DVT as a component of acute DVT did not differ significantly. CONCLUSIONS: Iliofemoral DVT may be more frequent than previously reported and represents a significant portion of acute DVT. Current recommendations of acute thrombus removal for the treatment of iliofemoral DVT is underutilized suggesting that perhaps greater education of clinicians and patients regarding invasive therapy for iliofemoral DVT is required.

Latissimus dorsi free flaps for complex ischiosacral defects.

BACKGROUND: Free tissue transfer for coverage of complex wounds in the ischial and sacral area can be limited by the lack of adequate recipient vessels. METHODS: We reviewed the records of 3 patients seen between August 2002 and December 2005 who underwent free tissue transfer to ischiosacral defects. RESULTS: Two patients were quadriplegic, and 1 patient was ambulatory. The gluteal vessels were used as recipients in 2 patients, and 1 patient had an arteriovenous loop to the femoral vessels. All flaps were successful and all wounds healed. CONCLUSIONS: A free latissimus flap to the ischiosacral area can be effective, and both local (gluteal) and regional (femoral) vessels can serve as recipient vessels.