There is much debate amoung colleagues and in the literature as to WHEN is the proper time to complete a lower extremity amputation or closure AFTER a lower extremity revsacularization has been completed.  Many say that there are different rules for endovascular vs. open bypass waiting periods.  I have had many discussions with my vascular surgeons here and it seems like most of this is still guesswork...  I am currious if any of you have strong feelings or experience on when is the best timing for completing or closing your foot procedure after the vascular folks have done their work?

>95% of the LE revascs in our hospital are currently performed by Interventional Cardiology.

We routinely close our patients POD#1 after endovascular work.

No-touch technique is used to preserve flap integrity in these high risk cases.

The cases requiring open bypass are variable as to when they are closed, and highly subjective.

Amputations, revision of open amputations, and delayed primary closures are typically done 1-3 days after revascularization.  If possible, revascularization is done prior to any ischemic limb requiring amputation.

Dear John,

I was taught "1 week!" by the best and the brightest of clinicians in the Cleveland Clinic. The theory is, even for a distal leg bypass case (which may result in an immediate return of pulsatile pedal pulses), it may take up to a week to "re-open" the smaller arteries & arterioles in a previously-ischemic limb.

The truth to be told, I think there is so many variables in this discussion, ie. the anatomy of the arterial stenosis, soft plaque vs. hard plaque, endo vs. open bypass, there is absolutely no way for us to come up with the appropriate timing, besides our best "guess-timate".

Many of my Japanese colleagues are interested in this topic, and they are gathering the SPP (Skin Perfusion Pressure) data after their re-vascularization processes to find out the "best timing" for amputation, or the "maximal point of return" in terms of SPP values. I've seen several attempts at this venture, but the numbers are still all over the map and no convincing conclusions yet.

For myself, I still go by the "1 week" rule, although I often take my patients to OR sooner, especially if they are already being admitted. 

Kazu Suzuki

Los Angeles, CA

Food for thought...

This is from one of the most prominent vascular surgeons in Japan (let's keep him anonymous for now).

When he sees a patient with gangrenous DM foot with ischemia, he would put the patient on the cath lab table, do toe/foot amputations there, then proceed to do angiogram/angioplasty/leg bypass as needed.

His theory is, he will have the least incident of bacteremia coming from the gangrenous wound, following the revascularization procedure, by doing it this way.

It's bold... but it does make sense to me. What do you think? 

While there is certainly value drawing from personal and expert opinions; there is data on this subject.  I think waiting as long as you can is good, however in this climate of DRGs and medicare along with insurance companies trying to reduce hospital stays, they may fall on data such as this. 

Arroyo et al., in 2002, asked the same question and answered with this study to determine the optimal waiting period for foot salvage surgery following limb revascularization.  They studied 11 patient with critical limb ischemia defined by transcutaneous oxygen tension (TcPO2) of 30 mm Hg or less. TcPO2 measurements were performed prior to lower extremity bypass and postoperatively at day 1, 2, and 3. The mean preoperative value (9.27 mm Hg) was compared with the mean value at postoperative day 1 (17.73 mm Hg), day 2 (20.36mm Hg), and day 3 (36.82 mm Hg).

Statistically significant differences in TcPO2 measurements were observed between preoperative and the 3rd postoperative day but not from 2nd to 3rd day, which leads to the recommendation that the 3rd postoperative day was the most optimal day to perform amputation. I usually wait 2-3 days.  At this point, the "critical" limb is being perfused.  Of course, no study is perfect, but this give us some evidence to guide our therapy.  

Arroyo, CI et al. J Foot Ankle Surg 41(4):228-232, 2002. 

Good info, George. I wonder if Day 7 is better than Day 3, then? I agree with you that the hospital/DRG system doesn't appreciate if I wait too long (a week?) to do a definitive amp. 

This would be a good research topic for the residents... you can measure TCOM or SPP after revascularization procedure at the same location, day 0 through 3, 7, 14, 30 etc. Since TCOM/SPP are non-invasive, all you need is a set of cooperative patients!  

All of the comments have merit, I agree with Kazu's July 28th comment.  I have done both over the years.  Now I prefer to amputate as the vascular surgeon is closing.

Karr 

I thought I remembered an article stating a significant distal perfusion at 72 hours. I can't remember the source. I'll try to hunt that down.

I do 5-10 amputations/week in my hospital. Most of them have had some type of vascular procedure...either stent/PTA/atherectomy/bypass. I typically wait 2-3 days to perform my amputation. That seems to work well. But on the other hand, sometimes situations arise where the vascualr surgeon will call me in at the end of their case and ask me to perform the amputation.  That is usually when the patient is quite sick and they don't want to put them under anesthesia twice or the patient is from far away....some reason.

Anyway, I don't have any data one way or the other. I'll start to pay attention but I can't say that waiting 7 days would make more sense over 3.  Yes, you don't want to keep them in the hospital, but sometimes we'll send them home if they are stable and bring them back a week or so after their bypass and do the amputation.  In my experience, I can't say patients do better by waiting one, three of seven days post bypass/atherectomy etc. But maybe it depends on the procedure too? OK to wait one day post atherectomy but 3 days post fem-pop?

I agree there is so much variability in this that it's hard to quantify, but maybe a study should be done to look at this.