A prognostic model for amputation in critical lower limb ischemia

In a (negative) multicenter randomized trial on management for inoperable critical lower limb ischemia, comparing spinal cord stimulation and best medical treatment, a number of pre-defined factors were analyzed for prognostic value. We included a radiological arterial disease score, modified from the SVS/ISCVS runoff score. The purpose of this analysis was to evaluate clinical factors and commonly used circulatory measurements for prognostic modeling in patients with critical lower limb ischemia. We determined the incidence of amputation and its relation to various pre-defined risk factors. A total of 120 patients with critical limb ischemia were included in the study. The integrity of circulation in the affected limb was evaluated on five levels: suprainguinal,infrainguinal, popliteal, infrapopliteal and pedal. A total radiological arterial disease score was calculated from 1 ( full integrity of circulation) to 20 (maximally compromised state). We used Cox regression analysis to quantify prognostic effects and differential treatment (predictive) effects. Major amputation occurred in 33% of the patients at 6 months and in 51% at 2 years. The presence of ischemic skin lesions and the radiological arterial disease score were independent prognostic factors for amputation. Patients with ulcerations or gangrene had a higher amputation risk (hazard ratio 2.38, p = 0.018 and 2.30, p = 0.036 respectively) as well as patients with a higher radiological arterial disease score (hazard ratio 1.17 per increment, p = 0.003). We did not observe significant interactions between prognostic factors and the effect of spinal cord stimulation. In conclusion, in patients with critical lower limb ischemia, the presence of ischemic skin lesions and the described radiological arterial disease score can be used to estimate amputation risk

Efficacy of subfascial endoscopy in eradicating perforating veins of the lower leg and its relation with venous ulcer healing

AbstractPurpose: The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg.Methods: All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy.Results: In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed.Conclusions: Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing. (J Vasc Surg 1997 26:255-9.