SLR - April 2023 - Yunkyung Jessica Lee, DPM
Title: Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemiaReference: Gomez-Sanchez C, Werlin E, Sorrentino T, El Khoury R, Lancaster E, Parks C, Goodman B, Dini M, Iannuzzi J, Reyzelman A, Conte MS, Gasper W. Open revascularization approach is associated with healing and ambulation after transmetatarsal amputation in patients with chronic limb threatening ischemia. J Vasc Surg. 2022 Dec 27:S0741-5214(22)02714-8. doi: 10.1016/j.jvs.2022.12.035. Epub ahead of print. PMID: 36581012.
Level of Evidence: Level III
Scientific Literature Review
Reviewed by: Yunkyung Jessica Lee, DPM
Residency Program: Eastern Virginia Medical School, Norfolk, VA
Podiatric Relevance: Transmetatarsal amputations (TMA) can be a viable treatment option for diabetic foot ulcers and other forefoot complications, but have variable reported healing rates depending on co-morbidities such as infection, chronic limb threatening ischemia (CLTI), and peripheral artery disease (PAD). Adequate blood flow is critical to achieve successful healing of TMAs which will further allow patients to maintain ambulatory function of the foot and avoid below-the-knee or above-the-knee amputations. The purpose of the current study was to evaluate outcomes of TMAs, particularly on patients with CLTI by comparing revascularization methods of endovascular versus open bypass.
Methods: A retrospective study of patients who underwent TMAs at three centers (university/tertiary referral medical center, Veterans Affairs medical center, and county hospital) were reviewed from 2008 to 2020. Peripheral artery disease was noted if ankle brachial index was < 0.9, arteries were noncompressible, or if stenosis was present on duplex ultrasound or angiography preoperatively. Patients were considered to be revascularized if the procedure occurred within a time frame of 6 months prior to or 1 month after receiving a TMA. Limb characteristics were based off the Society for Vascular Surgery lower extremity threatened limb classification system (WIfI [wound, ischemia, foot infection]), which is a three-category prognostic tool for patients with CLTI to clinically stage the affected limb for amputation risks at one year. The Global Limb Anatomic Staging System (GLASS) was used to grade angiographic images which separately scored the femoropopliteal and infrapopliteal segment based on patency for arterial revascularizations. The ambulatory status was determined as “community-level ambulation” if the patient required an assistive device to ambulate, “any degree of ambulation” if the patient was able to stand for transfer, and “non-ambulatory” if patient was bedbound or wheelchair bound. Patients were deemed healed if the surgical site was well healed after suture removal at 6 to 8 weeks.
Results: 318 patients underwent a total of 346 transmetatarsal amputations. 225 of these TMAs had PAD with approximately 85% being diabetic type I or diabetic type II. Revascularization was performed on 185 limbs with 102 limbs being revascularized following the endovascular approach and 83 limbs using an open/hybrid approach. Patients with PAD had lower rates of healing compared to ones without PAD (64% vs 77%; P = .007). 93% of the patients had a WIfI stage of 3 or 4, and 49% classified as GLASS stage 3. Postoperative “community-level ambulation” was more often observed after open revascularization (57% vs 34%; P = .002) in patients with GLASS stage 3. Overall, improved TMA healing was likely to be seen in post open revascularization (76% vs 55%; P = .003).
Conclusion: Predicting TMA healing in patients with CLTI can be difficult, but this study provided valuable data to suggest an optimal approach for revascularization in order to result in increased wound healing and higher ambulation rates. To avert major amputations and TMA failures, perhaps considering an open revascularization method as an initial intervention might be advantageous.