Darrell N. Jones

Recommended standards for reports dealing with lower extremity ischemia: Revised version

Recommended standards for analyzing and reporting on lower extremity ischemia were first published by the Journal of Vascular Surgery in 1986 after approval by the Joint Council of The Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. Many of these standards have been accepted and are used in the current literature on peripheral arterial occlusive disease. With the passage of time, some oversights, aspects that require clarification, and better modifications have been recognized. This report attempts to correct these shortcomings while reinforcing those recommendations that have proven satisfactory. Explanatory comments are added to facilitate understanding and application. This version is intended to replace the original version.

Functional outcome in a contemporary series of major lower extremity amputations

PURPOSE We undertook this study to document the functional natural history of patients undergoing major amputation in an academic vascular surgery and rehabilitation medicine practice. METHODS A retrospective review was conducted of consecutive patients undergoing major lower extremity amputation and rehabilitation in a university and Department of Veterans Affairs hospital. Main outcome variables included operative mortality, follow-up, survival, median time to incision healing, secondary operative procedures for wound management, and conversion from below-knee amputation (BKA) to above-knee amputation (AKA). For surviving patients, quality of life was determined by degree of ambulation, eg, outdoors, indoors only, or no ambulation; use of a prosthesis; and independence, eg, community housing or nursing facility. RESULTS From August 1997 through March 2002, 154 patients (130 men; median age, 62 years) underwent 172 major amputations, 78 AKA and 94 BKA, because of either critical limb ischemia (87%) or diabetic neuropathy (13%). Thirty-day operative mortality was 10%. Mean follow-up was 14 months. Healing at 100 and 200 days, as determined with the Kaplan-Meier method, was 55% and 83%, respectively, for BKA, and 76% and 85%, respectively, for AKA. Twenty-three BKA and 16 AKA required additional operative revision, and 18 BKA ultimately were converted to AKA. Survival was 78% at 1 year and 55% at 3 years. Function in surviving patients at 10 and 17 months, respectively, was as follows: 21% and 29% of patients ambulated outdoors, 28% and 25% ambulated indoors only, and 51% and 46% of patients were nonambulatory; 32% and 42% of patients used prosthetic limbs; and 17% and 8% of patients who lived in the community before amputation required care in a nursing facility. CONCLUSIONS We were surprised to find that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite infrequent prosthesis use and outdoor ambulation. Although any hope for postoperative ambulation in this population requires salvaging the knee joint, because of the morbidity incurred in both wound healing and rehabilitation efforts, aggressive effort should be reserved for selected patients at good risk. Ability to predict ambulation after BKA in the vascular population is poor.

The role of hemodynamics and duplex ultrasound in the diagnosis of peripheral arterial disease.

Recent reports have suggested that duplex ultrasound should replace hemodynamic measurements and the use of the ankle-to-arm systolic blood pressure ratio in evaluating patients with peripheral arterial disease. Measurement of peripheral hemodynamics in patients with peripheral arterial disease is well established and can be used for screening populations at risk for peripheral arterial disease; the finding of an abnormal ankle-to-arm ratio is associated with a high risk of cardiovascular morbidity and mortality. With the ankle-to-arm ratio, the diagnosis of vascular disease can be established in symptomatic patients and initial treatment plans can be formulated. In contrast, duplex ultrasound provides accurate information on vessel morphology and changes in blood-flow velocity in specific areas of stenosis. The test is noninvasive, and in some situations the duplex instrument may be superior to an angiogram in detecting patent distal vessels. Because it is more expensive and time-intensive than measuring peripheral pressures, duplex ultrasound should be used in selected patients in whom the knowledge of actual vessel morphology is critical to the patients treatment.

Progressive and measurable experimental arterial stenosis: A new technique

A technique of retrospective axial photography for the measurement of progressive arterial stenoses by an external loop constricting device, developed and evaluated in 27 experiments on the canine aorta, is described. The method of analysis not only indicated a greater than 95% reliability for this method but demonstrates a major source of error inherent in previous methods in which estimates of luminal area are based on external measurements.