Multidisciplinary Amputation Prevention at the DeBakey VA Hospital: Our First Decade.

Background: In 2011, the Veterans Health Administration (VHA) undertook multidisciplinary efforts to improve care for patients with nonhealing foot ulcers and reduce leg amputation rates. This article examines the impact of interdisciplinary care for amputation prevention in the VHA.

Methods: The VHA patient population was characterized using internal registries.

Advanced Wound, Ischemia, and foot Infection stage is associated with poor outcomes in the BEST-CLI trial.

Objective: Wound, Ischemia, and foot Infection (WIfI) staging was established to provide objective classification in patients with chronic limb-threatening ischemia (CLTI) and to predict 1-year major amputation risk. Our goal was to validate WIfI staging using data from the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial.

Methods: Data from the BEST-CLI Trial, a prospective randomized trial comparing surgical revascularization (OPEN) and endovascular revascularization (ENDO), were used to assess the association of WIfI stage on long-term outcomes in an intention-to-treat analysis.

Specialist access and leg amputations among Texas Medicaid patients.

Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas.

Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia.

Introduction: The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI).

Methods: We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers.

Polymicrobial Foot Infection Patterns Are Common and Associated With Treatment Failure.

Background: That foot infections are predominately polymicrobial has long been recognized, but it is not clear if the various species co-occur randomly or in patterns. We sought nonrandom species co-occurrence patterns that might help better predict prognosis or guide antimicrobial selection.

Methods: We analyzed tissue (bone, skin, and other soft tissue), fluid, and swab specimens collected from initial foot infection episodes during a 10-year period using a hospital registry.

Severe anemia, anorexia, and uremia associated with diabetic foot infections: A case series.

Anemia of inflammation, as found in many chronic disease states, is common among persons with diabetic foot infections but is typically mild and self-limited. Herein we present four cases of patients with foot infections accompanied by severe anemia (nadir hemoglobin <8 gm/dL and resulting in transfusion of 4 + units of blood) as well as significant weight loss (30 + pounds), hyponatremia (<135 mmol/L), hypoalbuminemia (nadir <2 gm/dL), uremia and other metabolic derangements.

Hospital Payer Mix and Amputation Rates Among Patients with Peripheral Artery Disease Complications.

Background: Studies have shown that Medicaid coverage is associated with higher rates of primary amputation among patients with peripheral artery disease (PAD). We sought to identify whether hospital payer makeup also influences outcomes among these patients.

Methods: Patients who underwent treatment for foot complications in Texas were identified and aggregated by hospital.

Racial and ethnic disparities in abdominal aortic aneurysm evaluation and treatment rates in Texas.

Background: Screening identifies intact abdominal aortic aneurysms (iAAAs) before progression to ruptured AAAs (rAAAs). However, screening efforts have been limited by the low overall diagnostic yield and unequal screening among minority populations. The goal of the present study was to identify equitable AAA screening strategies for both majority and minority populations.

Gender, racial and ethnic disparities in index hospitalization operations for symptomatic carotid stenosis in Texas hospitals.

Background: Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease.

Healthcare disparities in vascular surgery: A critical review.

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White.

Outcomes after Endovascular Stent Placement for Long-Segment Superficial Femoral Artery Lesions.

Background: Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain.

Methods: A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES).

Wound Complications and Reoperations after Transtibial Amputation of the Leg.

Background: Transtibial amputations (TTAs) of the leg have been associated with high rates of wound complications. We assessed outcomes of TTAs to determine if bundled interventions implemented at our hospital had an impact on lowering wound complications, including surgical site infections.

Methods: We assessed the impact of a surgical site infection prevention bundle (negative-pressure wound therapy, minimizing the use of staples, and a decontamination protocol for methicillin-resistant Staphylococcus aureus) on 90-day wound complications.

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications.

Aims: The optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations.

Endovascular Therapy in an "All-Comers" Risk Group for Chronic Limb-Threatening Ischemia Demonstrates Safety and Efficacy When Compared with the Established Performance Criteria Proposed by the Society for Vascular Surgery.

Background: The aim of this study was to describe the applicability of the Society for Vascular Surgery (SVS) objective performance goals (OPGs) as a tool to evaluate results in the context of endovascular management of noncomplex and complex patients (i.e., end stage renal disease/history of prosthetic conduit) with chronic limb-threatening ischemia (CLTI).

Leg Amputations Among Texans Remote From Experienced Surgical Care.

Background: Surgical outcomes may differ between low-volume and experienced hospitals. We sought to identify characteristics of remote patients-those living more than 50 miles from an experienced center-who underwent leg amputations for peripheral artery disease (PAD) and foot complications at low-volume and experienced hospitals and identify regions of Texas where such patients live.

Materials And Methods: Publicly available Texas hospitalization data from 2004 through 2009 were used to identify patients with PAD who underwent leg amputation for foot complications, including foot ulcers, foot infections, and gangrene.

Long-term outcomes of lower extremity graft preservation using antibiotic beads in patients with early deep wound infections after major arterial reconstructions.

Objective: Bypass graft preservation with wound sterilization using serial antibiotic bead exchange has been described in patients presenting with deep wound infections after extremity bypass. The long-term benefits of this approach remain poorly understood. We examined whether graft preservation and wound sterilization with antibiotic beads affect amputation rates and patient survival.

Delayed gratification and adherence to exercise among patients with claudication.

Few studies have explicitly identified factors that explain an individual's willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication.

Arteriovenous fistula maturation rate is not affected by ipsilateral tunneled dialysis catheter.

Objective: The effect that ipsilateral tunneled dialysis catheters (TDC) have on arteriovenous fistula (AVF) maturation is unclear. We sought to define this association by comparing AVF maturation rates in patients with contralateral TDC with those with ipsilateral TDC.

Methods: A review of a prospectively maintained database including all AVF creation procedures between 2009 and 2016 was performed.

Health Care Resource Distribution of Texas Counties With High Rates of Leg Amputations.

Background: Lower extremity amputation rates associated with peripheral arterial disease in Texas are high and vary disproportionately among different populations. We sought to assess the impact of socioeconomic status and health care resource distribution on the geographic prevalence of lower extremity amputation in Texas counties.

Materials And Methods: We collated 2005-2009 data on all 254 Texas counties.

Advances in the Management of Peripheral Artery Disease.

Purpose Of Review: This paper provides a concise update on the management of peripheral artery disease (PAD).

Recent Findings: PAD continues to denote a population at high risk for mortality but represents a threat for limb loss only when associated with foot ulcers, gangrene, or infections. Performing either angiogram or non-invasive testing for all patients with foot ulcers, gangrene, or foot infections will help increase the detection of PAD, and refined revascularization strategies may help optimize wound healing in this patient group.

Long-Term Wound Palliation to Manage Exposed Hardware in the Setting of Peripheral Arterial Disease.

Exposed orthopedic hardware in the lower extremity complicated by peripheral arterial disease typically demands multiple operative procedures by several disciplines to maintain skeletal integrity and achieve complete wound healing. For ambulatory patients that are either not candidates for lower extremity revascularization or prefer not to pursue surgical attempts at limb preservation, wound palliation is a potential management strategy. We discuss a patient with a history of severe peripheral arterial disease and a left pilon fracture previously treated with open reduction and internal fixation.

RACIAL AND GEOGRAPHIC VARIATION IN LEG AMPUTATIONS AMONG TEXANS.

Background: The existence of racial and ethnic disparities in leg amputations rates is well documented. Despite this, approaches to addressing these alarming disparities have been hampered by the inability to identify at-risk individuals in a region and design targeted interventions. We undertook this study to identify small geographic areas in which efforts focused on high-risk individuals with peripheral artery disease (PAD) could address disparities in leg amputation rates.

Discordant isolates in bone specimens from patients with recurrent foot osteomyelitis.

We compared paired operative bone cultures (initial operation and reoperation) for 35 patients who experienced foot osteomyelitis treatment failure at a single hospital. Concordance was poor (kappa = 0.180).