ABOVE-KNEE AMPUTATION STUMP ISCHEMIA: A SURGICAL CHALLENGE IN PREVENTING DEATH
Introduction: Above-knee stump ischemia is a serious condition. If left untreated usually courses with progression to irreversible ischemia. Without treatment the path from here usually leads to hip disarticulation and death. Our aim is to present our most recent experience in stump revascularization.
Material/Methods: We retrospectively reviewed all patients with above-knee stump ischemia treated in our institution between July 2018 to March 2019.
Results: We present four clinical cases treated in our institution in the last nine months. Two of them presented with non-acute stump ischemia with pain and skin lesions developed after minor trauma several months after surgery and stump healing. In both cases the computed tomography angiography (CTA) showed occlusion of the common femoral artery (CFA) and was inconclusive regarding the status and quality of the deep femoral artery (DFA). Despite this, ischemia severity deemed obligatory an attempt to revascularization, DFA was surgically exposed and proved to be an adequate target run off to a bypass. In the other two, the ischemia of the stump was acute. In one patient it was after surgical treatment of an ipsilateral false aneurism of the CFA (with ligation of the EIA) treated with a bypass from the EIA to both the superficial and DFA. The other was a patient admitted with aortic bifurcation occlusion and irreversible right leg ischemia that was submitted to primary above-knee amputation. In the next postoperative days, the patient developed severe stump ischemia. An axillo femoral bypass and proximal re-amputation was performed. Three patients resolved the stump ischemia and fared well, the last one died in the postoperative period.
Discussion/Conclusions: Above-knee stump ischemia usually leads to progressive stump degradation/necrosis/infection, eventually leading to death. When the common/deep femoral arteries are occluded, re-amputation is usually insufficient and progression of ischemia can dictate the need for a hip disarticulation, a very aggressive and mutilating procedure with high rate of morbidity and mortality that do not prevent progression to pelvic ischemia and death. Revascularization of above-knee amputation stump, based on DFA or hypogastric revascularization, is the best therapeutic alternative and should be attempted even in frail patients. We believe that our small series reinforces the idea that stump revascularization is possible and can save both: stump and life.
2. Blunt TJ, Manship LR, Bynoe RP, Haynes JL. Lower extremity amputation for peripheral vascular disease: A low risk operation. Am Surg 50.1984(11):581-584.
3. Kwaan JHM, Connolly JE. Fatal sequelae of the ischemic amputation stump: A surgical challenge. Arch Surg 138. 1979: 49-52.
4. Affonso BB, Motta-Leal-Filho JM, Cavalcante RN, Falsarella PM, Galastri FL, Cardoso RS, et al. Intra-arterial fibrinolysis for the management of acute ischemia on a below-knee amputation stump. Case report . Einstein (São Paulo) 16. 2018: 1-4.
5. Laszlo G, Kullmann L. Hip disarticulation in peripheral vascular disease. Arch Orthop Trauma Surg, 1987: 126-128.
6. Unruh T, Fisher DF Jr, Unruh TA, Gottschalk F, Fry RE, Clagett GP, et al. Hip disarticulation. An 11 year experience. Arch Surg 125. 1990:791-793.
7. Endean ED, Schwarcz TH, Barker DE, Munfakh NA, Wilson-Neely R, Hyde GL. Hip disarticulation: factors affecting outcome. J Vasc Surg.1991:398-404.
8. Remes L, Isoaho R, Vahlberg T, Viitanen M, Rautava P. Predictors for institutionalization and prosthetic ambulation after major lower
extremity amputation during an eight-year follow-up. Aging Clin Exp Res.2009:129-135.
9. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil. 2001:776-779.
10. Moura D, Garruço A. Desarticulação da anca — Análise de uma série e revisão da literatura. Rev Bras Ortop, 2016: 1-5.
11. Dénes Z, Till A. Rehabilitation of patients after hipdisarticulation. Arch Orthop Trauma Surg. 1997:498-499.
12. Fenelon GC, Von Foerster G, Engelbrecht E. Disarticulation ofthe hip as a result of failed arthroplasty. A series of 11 cases. J Bone Joint Surg Br 1980:441-446.
13. Jain R, Grimer RJ, Carter SR, Tillman RM, Abudu AA. Outcome after disarticulation of the hip for sarcomas. Eur J Surg Oncol. 2005:1025-1028.
14. Daigeler A, Lehnhardt M, Khadra A, Hauser J, Steinstraesser L,Langer S, et al. Proximal major limb amputations — a retrospective analysis of 45 oncological cases. World J Surg Oncol. 2009:1-10.
15. Ebrahimzadeh MH, Kachooei AR, Soroush MR, HasankhaniEG, Razi S, Birjandinejad A. Long-term clinical outcomes ofwar-related hip disarticulation
and transpelvic amputation. J Bone Joint Surg Am. 2013:1-6.
16. Zalavras CG, Rigopoulos N, Ahlmann E, Patzakis MJ. Hipdisarticulation for severe lower extremity infections. Clin Orthop Relat Res. 2009:1721-1726.
17. Nowroozi F, Salvanelli ML, Gerber LH. Energy expenditure inhip disarticulation and hemipelvectomy amputees. Arch PhysMed Rehabil. 1983:300-303.
18. Columbo JA, Ptak JA, Buckey JC, Walsh DB. Hyperbaric oxygen for patients with above-knee amputations, persistent ischemia, and nonreconstructable vascular disease. J Vasc Surg. 2016:1082-1084.
19. Drenjancevic I, Kibel A. Restoring vascular function with hyperbaric oxygen treatment: recovery mechanisms. J Vasc Res 2014:1-13.
20. Wattel F, Mathieu D, Coget JM, Billard V. Hyperbaric oxygen therapy in chronic vascular wound management. Angiology. 1990:59-65.
21. Stoekenbroek RM, Santema TB, Legemate DA, Ubbink DT, van den Brink A, Koelemay MJ. Hyperbaric oxygen for the treatment of diabetic foot ulcers: a systematic review. Eur J Vasc Endovasc Surg. 2014:647-655.
22. Heyboer M 3rd, GrantWD, ByrneJ,PonsP, Morgan M, Iqbal B,et al. Hyperbaric oxygen for the treatment of nonhealing arterial insufficiency ulcers. Wound Repair Regen. 2014:351-355.
23. Margolis DJ, Gupta J, Hoffstad O, Papdopoulos M, Glick HA, Thom SR, et al. Lack of effectiveness of hyperbaric oxygen therapy for the
treatment of diabetic foot ulcer and the prevention ofamputation: a cohort study. Diabetes Care. 2013:1961-1966.