SLR - April 2021 - Katrin Heineman

Wound Location is Independently Associated with Adverse Outcomes Following First-Time Revascularization for Tissue Loss

Reference: Darling JD, O'Donnell TFX, Vu GH, Norman AV, St John E, Stangenberg L, Wyers MC, Hamdan AD, Schermerhorn ML. Wound Location is Independently Associated with Adverse Outcomes Following First-Time Revascularization for Tissue Loss. J Vasc Surg. 2020 Aug; 29: S0741-5214(20)31883-8. doi: 10.1016/j.jvs.2020.07.091.

Level of Evidence: Level III

Scientific Literature Review

Reviewed By: Katrin Heineman, DPM
Residency Program: Temple University Hospital – Philadelphia, PA

Podiatric Relevance: Diabetic foot ulcers are one of the leading risk factors for lower extremity amputation. The diabetic population is at high risk for lower extremity ulceration secondary to neuropathy, ischemia, or both and numerous studies have noted the increased risk of mortality following an amputation. It is our goal as podiatric surgeons to recognize the significance of lower extremity ulcerations and help slow the cascade. The authors assessed the relationship between lower extremity wound location and long-term outcomes in patients with tissue loss undergoing any first-time lower extremity revascularization. 

Methods: The authors retrospectively reviewed all patients undergoing first-time open bypass or percutaneous transluminal angioplasty with or without stenting for tissue loss between 2005 and 2015. Exclusion criteria included prior infrainguinal intervention on the ipsilateral limb, interventions proximal to the CFA, or limbs with multiple wounds. Follow-up consisted of visits every three to four months for two years and every six months thereafter. Wounds were categorized into three groups: forefoot, midfoot, and heel. Primary outcomes included perioperative complications, wound healing, re-intervention, limb salvage, amputation-free survival (AFS), and survival. Perioperative complications included acute kidney injury (AKI), myocardial infarction (MI), stroke, and death. In total, 576 limbs (forefoot = 397, midfoot = 61, heel = 118) were included in the study.  

Results: Patients undergoing first-time revascularization for tissue loss with forefoot, midfoot, and heel wounds experienced similar rates of perioperative mortality (1.3 percent vs 4.9 percent vs 4.2 percent). Perioperative complications did not differ in the three groups, including stroke (0.3 percent vs 1.6 percent vs 0.9), acute MI (1.0 percent vs 0 percent vs 2.5 percent), and AKI (2.8 percent vs 4.9 percent vs 5.9 percent). Complete wound healing at six-months was significantly different between the three groups (forefoot 49 percent vs. midfoot 46 percent vs. heel 39 percent). Heel wounds were associated with higher rates of incomplete 6-month wound healing, major amputation, or mortality. In bypass patients, heel wounds were associated with an increased risk of all-cause mortality. In angioplasty patients, heel wounds were associated with an increased risk of incomplete wound healing, major amputation or mortality, and all-cause mortality. 

Conclusions: The authors concluded that heel wounds place the patient at risk for increased rates of incomplete wound healing, decreased amputation-free survival and all-cause survival compared with midfoot or forefoot wounds in patients undergoing any first-time lower extremity revascularization for soft tissue loss. Patients undergoing first percutaneous transluminal angioplasty interventions are at higher risk for these complications. Limb salvage is a multi-disciplinary approach. It is our duty as podiatric surgeons to educate our patients and encourage a close relationship with our vascular surgery colleagues. 

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