Transmetatarsal Amputation: What is the Optimal Revascularization - - PDF document

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Transmetatarsal Amputation: What is the Optimal Revascularization - - PDF document

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Transmetatarsal Amputation: What is the Optimal Revascularization Strategy? Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery Chief, Vascular Surgery Section San Francisco VA Health Care System UCSF Vascular Surgery

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[ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES AND HANDOUTS] 4/8/19 1

Transmetatarsal Amputation: What is the Optimal Revascularization Strategy?

Warren Gasper MD Assistant Professor of Surgery UCSF Vascular Surgery Chief, Vascular Surgery Section San Francisco VA Health Care System 4/5/2019 UCSF Vascular Surgery Symposium 2019

Disclosures:

None

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Transmetatarsal Amputation (TMA)

§ First described by Bernard and Huete in 1855 for trench foot then refined by McKittrick in 1949 for the management of gangrene and diabetic foot infections, transmetatarsal amputation (TMA) provides the opportunity for limb salvage in the face of extensive digit and forefoot wounds § Opportunity to maintain ambulatory status in patients with severe limb threat due to infection, ischemia or both

  • Excluding cases for trauma, series report 60-80% of patients with healed

TMAs are ambulatory

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Wallace, Clin Podiatr Med Surg 2005 | Landry, Arch Surg 2011.

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Ambulatory Status Co-morbidities Extent of tissue loss Ischemia Infection Provider and patient commitment to frequent follow-up Patient compliance TMA length Soft tissue coverage Foot stability/ROM

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20 years of TMA results: 1 year limb salvage rates 50-70% 1 year major amputation rates 30-40% 3-year survival rates of 35-65% 1-year reintervention/wound rate 30-40%

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Rising to the challenge of the TMA

§ Many series are from vascular centers and are biased to PAD § Peripheral artery disease is associated with a 2-3 times increase in risk of major amputation and death § End stage renal disease is also a strong risk factor for major amputation and death

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Months

Roukis, Foot Ankl Spec 2010

UCSF TMA Experience

Total (n=135) PAD (n=88) No PAD (n=47) p Age, y 61.5 ± 11.5 64.4 ± 11.3 55.9 ± 9.9 <.001 Male gender 109 (81%) 67 (76%) 42 (89%) .06 BMI 28.7 ± 6.5 28.1 ± 6.4 29.6 ± 6.7 .3 HTN 110 (81%) 74 (84%) 36 (77%) .3 DM 118 (87%) 76 (86%) 42 (89%) .5 CAD 44 (33%) 43 (49%) 1 (2%) <.001 PAD 88 (65%) 88 (100%) 0 (0%) <.001 COPD 10 (7%) 9 (10%) 1 (2%) .09 CKD 39 (29%) 29 (33%) 10 (21%) .2 ESRD 23 (17%) 19 (22%) 4 (9%) .05 Prior CVA 14 (10%) 13 (15%) 1 (2%) .02 HIV 3 (2%) 1 (1%) 2 (4%) .2 Organ transplant 8 (6%) 7 (8%) 1 (2%) .2 Wound grade Wifi 1/2 20 (15%) 8 (9%) 12 (26%) .01 Wifi 3 57 (42%) 34 (39%) 23 (49%) .2 Wifi 4 58 (43%) 46 (52%) 12 (25%) .003

§ 147 consecutive TMAs in 135 patients from 2008 to 2016 at UCSF, SFGH and SFVA

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Who does not have PAD?

Total (n=135) PAD (n=88) No PAD (n=47) p Age, y 61.5 ± 11.5 64.4 ± 11.3 55.9 ± 9.9 <.001 Male gender 109 (81%) 67 (76%) 42 (89%) .06 BMI 28.7 ± 6.5 28.1 ± 6.4 29.6 ± 6.7 .3 HTN 110 (81%) 74 (84%) 36 (77%) .3 DM 118 (87%) 76 (86%) 42 (89%) .5 CAD 44 (33%) 43 (49%) 1 (2%) <.001 PAD 88 (65%) 88 (100%) 0 (0%) <.001 COPD 10 (7%) 9 (10%) 1 (2%) .09 CKD 39 (29%) 29 (33%) 10 (21%) .2 ESRD 23 (17%) 19 (22%) 4 (9%) .05 Prior CVA 14 (10%) 13 (15%) 1 (2%) .02 HIV 3 (2%) 1 (1%) 2 (4%) .2 Organ transplant 8 (6%) 7 (8%) 1 (2%) .2 Wound grade Wifi 1/2 20 (15%) 8 (9%) 12 (26%) .01 Wifi 3 57 (42%) 34 (39%) 23 (49%) .2 Wifi 4 58 (43%) 46 (52%) 12 (25%) .003

§ Only 45% of limbs had an ABI, 1/3

  • f the values were >1.3

§ Only 24% of limbs had a toe pressure ØClearly PAD is under diagnosed ØAn accurate quantitative measure

  • f ischemia is difficult

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UCSF TMA Experience

Total (n=135) PAD (n=88) No PAD (n=47) p Age, y 61.5 ± 11.5 64.4 ± 11.3 55.9 ± 9.9 <.001 Male gender 109 (81%) 67 (76%) 42 (89%) .06 BMI 28.7 ± 6.5 28.1 ± 6.4 29.6 ± 6.7 .3 HTN 110 (81%) 74 (84%) 36 (77%) .3 DM 118 (87%) 76 (86%) 42 (89%) .5 CAD 44 (33%) 43 (49%) 1 (2%) <.001 PAD 88 (65%) 88 (100%) 0 (0%) <.001 COPD 10 (7%) 9 (10%) 1 (2%) .09 CKD 39 (29%) 29 (33%) 10 (21%) .2 ESRD 23 (17%) 19 (22%) 4 (9%) .05 Prior CVA 14 (10%) 13 (15%) 1 (2%) .02 HIV 3 (2%) 1 (1%) 2 (4%) .2 Organ transplant 8 (6%) 7 (8%) 1 (2%) .2 Wound grade Wifi 1/2 20 (15%) 8 (9%) 12 (26%) .01 Wifi 3 57 (42%) 34 (39%) 23 (49%) .2 Wifi 4 58 (43%) 46 (52%) 12 (25%) .003

§ 147 consecutive TMAs in 135 patients from 2008 to 2016 at UCSF, SFGH and SFVA § Median follow-up was 3.3 years § Overall TMA healing rate 60%

  • 75% non-PAD vs 52% PAD

§ Major Amputation rate 22%

  • 10% non-PAD vs 28% PAD

§ 3-year survival 75% by KM

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UCSF TMA Experience

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0.00 0.25 0.50 0.75 1.00 88 76 54 40 22 16 PAD 47 46 40 30 16 11 No PAD Number at risk 1 2 3 4 5 analysis time (y) No PAD PAD p = 0.02 (Log-rank)

Overall Survival

0.00 0.25 0.50 0.75 1.00 94 42 26 18 5 5 PAD 51 17 8 6 3 2 No PAD Number at risk 1 2 3 4 5 analysis time (y) No PAD PAD p = 0.003 (Log-rank)

Rates of TMA Healing

UCSF TMA Experience

§ 61 limbs had a revascularization procedure during the index TMA hospitalization

  • Timing: revasc + TMA occurred

within 4d (median, IQR 2-7d)

  • 87% of revascularizations
  • ccurred before TMA

§ Improvement in TMA healing rate for PAD pts (71% vs 57%) § Late revascularization did not help § Graft/vessel patency was associated with healing and limb loss

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Endo Open

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Timing of Revascularization and TMA

§ Sheahan et al (2005) found that a revascularization after toe amputation was associated with an increased risk of major limb loss (OR 2.11 95%CI 1.39-4.21) compared to bypass before amputation § Shi et al (2018) found no difference in the timing of revascularization (*all bypass procedures were pre-TMA). However TMA healing with endovascular procedures was similar to no treatment

  • Endovascular 50.6% vs Bypass 87%
  • No treatment 51%

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Sheahan, JVS 2005 | Shi J Foot Ankl Surg 2018

Adequate Perfusion after TMA: do you have it?

§ The plantar flap is fed by the posterior tibial artery § Angiographic characteristics of the foot were also investigated in a subset of the UCSF cohort using the GLASS and Kawarada scoring systems

  • Intact pedal arch and 2 pedal

arteries on the foot were associated with healing (p=.07)

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  • Fig. 4. Anterior tibial artery insufficiency. In the situation of anterior tibial artery insuf-

ficiency, flow through the posterior tibial artery to the plantar flap is antegrade, while flow through the dorsalis pedis artery to the dorsal flap is retrograde. If the anastomosis is

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Conclusions

§ Transmetatarsal amputations are a valuable but demanding procedure for limb salvage, even in patients with PAD § Revascularization prior to TMA appears to perform significantly better § Open surgery (bypass) has significantly better outcomes than endovascular § Peripheral artery disease is under diagnosed in patients with advanced limb threat (calcified toes, lack of accurate toe measurements, urgent surgery for infection)

  • Palpable pulses are not sufficient to assess for adequate perfusion before TMA

§ Angiosome and pedal arch anatomy have real clinical correlations but the value of targeted revascularization is unclear

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§ Risk prediction model for 1-year mortality after a lower extremity amputation – AMPREDICT-Mortality

  • Developed with VASQIP data from 5028

patients with PAD and/or diabetes undergoing their first TMA, BKA or AKA

  • Validated using VASQIP data from 2140

patients in different geographical locations from the development set

  • AUC 0.76

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Norvell, Br J Surg 2019

1-year mortality = eS/(1+eS) S = the sum of risk coefficients

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Norvell, Br J Surg 2019

Table 4 Mortality risk score coefficients for individual predictors in the ten-variable mortality prediction model (7168 combined development and validation samples) Coefficient Baseline for transmetatarsal –2⋅192 Baseline for transtibial –1⋅897 Baseline for transfemoral –1⋅717 Age (years) +0⋅047 × (Age – 60) BMI (kg/m2) –0⋅050 × (BMI – 25) Black race –0⋅257 Race other than black/white/Hispanic –0⋅985 Partially dependent functional status +0⋅303 Totally dependent functional status +0⋅955 Ever diagnosed with CHF +0⋅545 Currently on dialysis +0⋅900 BUN (mg/dl) +0⋅016 × (BUN – 25) WBC count ≥ 11 000/μl +0⋅342 Platelet count (× 106/ml) +1⋅720 × [(P/100)–0⋅5 – 0⋅577] The mortality risk score (S) for an individual is the sum of the coef-

70 year old white male with PAD and/or DM, partially dependent functional status, no CHF, no dialysis, normal WBC, BUN and platelet count Estimated 1-year mortality Above knee amputation: 35% Below knee amputation: 31% Transmetatarsal amp: 25%

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UCSF TMA Experience

§ Reviewed 147 consecutive TMAs in 135 patients from 2008 to 2016 at UCSF, SFGH and SFVA § Median follow-up was 3.3 years § Overall TMA healing rate 60% § Major Amputation rate 22% § 3-year survival 75% by KM § 65% of TMAs were done in limbs with PAD

Healed TMA (n=88) Non healed TMA (n=59) p Age (years) 60.1 ± 1.2 63.3 ± 1.5 .1 Male 74 (84%) 46 (78%) .3 BMI 29.2 ± 0.7 28.4 ± 1.0 .5 HTN 72 48 .9 DM 76 (86%) 53 (89%) .6 CAD 22 (25%) 26 (44%) .02 PAD 49 (56%) 46 (78%) .006 COPD 7 (8%) 3 (5%) .5 CKD 27 (31%) 15 (25%) .5 ESRD 14 (16%) 11 (19%) .7 Prior CVA 12 (14%) 5 (8%) .3 HIV 2 (2%) 1 (2%) .8 Organ transplant 5 (6%) 5 (8%) .5 Treated by MDLST 56 (63%) 48 (81%) .02 WIfI Stage Stage 1/2 15 (17%) 5 (8%) .1 Stage 3 35 (40%) 29 (49%) .3 Stage 4 38 (43%) 25 (42%) .9

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