Management of ischemic heel ulceration and gangrene: An evaluation of factors associated with successful healing

Abstract

The objective of this study was to determine the effectiveness of treatment of nonhealing heel ulcers and gangrene and to define those variables that are associated with success. Methods: A multi-institutional review was undertaken at four university or universityaffiliated hospitals of all patients with wounds of the heel and arterial insufficiency, which was defined as absent pedal pulses and a decreased ankle/brachial index (ABI). Risk factors, hemodynamic parameters, and arteriographic findings were statistically analyzed to determine their effect on wound healing. Life-table analysis was used to assess graft patency and wound healing. Results: Ninety-one patients (57 men, 34 women) were treated for heel wounds that did not heal for 1 to 12 months (62% of nonhealing wounds, 3 months or longer). The mean preoperative ABI was 0.51, and 31% of wounds were infected. Of the patients, 55% had impaired renal function (Cr > 1.5), with 24% undergoing dialysis, 70% had diabetes, and 64% smoked cigarettes. Treatment was topical wound care for all patients and operative wound débridement in 50%. Infrainguinal bypass was performed for 81 patients, 4 had inflow procedures, 3 had superficial femoral artery percutaneous transluminal angioplasty, and 3 had primary below-knee amputation. Postoperatively, 85% of patients had in-line flow to the foot with at least a single patent vessel, 66% had a pedal pulse, and the mean ABI improved by 0.40, to 0.91. Follow-up ranged from 1 to 60 months (mean, 21 months), and 77 patients (85%) are currently alive. In 66 patients (73%), the wounds healed-all within 6 months (mean, 3 months). For 14 (16%) the wounds had not healed, and 11 patients (11%) underwent below-knee amputation. By life-table analysis, limb salvage was 86% at 3 years. During follow-up, 75 infrainguinal bypasses (91%) remained patent (3 secondarily) and 6 occluded, with primary assisted patency of 87% at 3 years. All wounds in patients with occluded grafts failed to heal. Variables found to be statistically significant in predicting healing included normal renal function (95% healed vs 55% nonhealed, P < .002), a palpable pedal pulse (85% healed vs 42%, P < .0015), a patent posterior tibial artery past the ankle (86% healed vs 57%, P < .02), and the number of patent tibial arteries after bypass to the ankle (P < .0001). Neither the ABI nor the presence of infection (defined as positive tissue cultures or the presence of osteomyelitis), diabetes, or other cardiovascular risk factors influenced the outcome. Conclusions: Complete wound healing of ischemic heel ulcers or gangrene may require up to 6 months, and short-term graft patency is of minimal benefit. Successful arterial reconstruction, especially a patent posterior tibial artery after bypass, is effective in treating most heel ulcers or gangrene. Patients with impaired renal function are at increased risk for failure of treatment, but their wounds may successfully heal and they should not be denied revascularization procedures.

External Aggression to the Limb as a Predictive Factor in the Evolution of Patients Undergoing Arterial Revascularization

“…13 It is worth emphasizing that we did not observe any specific characteristics in the ischemic lesions that were correlated with the mechanism of lesion formation (i.e., spontaneous or secondary to external aggression).…”

Chronic renal impairment and surgical site infection in patients undergoing infrainguinal revascularisation: Results of a matched case-control study

“…In our cohort of 192 patients undergoing revascularisation, 13% (24 patients) had chronic renal insufficiency according to our criteria, representing a substantial proportion of our clinical case burden. We used a defining criterion for renal impairment of a serum creatinine value greater than 150 mmol/L, as used by other authors [7,9]; our criterion differed slightly from theirs by only including those patients who had recorded elevated serum creatinine on two occasions, three months apart, prior to surgery, in order to ensure that renal impairment was long-standing. The use of this selection criterion led to the inclusion of a majority of cases who were not receiving any renal support at the time of surgery.…”

“…Patients receiving active renal support by haemodialysis, or continuous ambulatory peritoneal dialysis, or who had a serum creatinine value >150 mmol/L (1.7 mg/dL), on at least two separate occasions, three months apart, prior to surgery, were regarded as having chronic renal impairment. A single serum creatinine value has been used by other authors as an inclusion criterion for CRI in similar studies [7,9], but we only included patients with elevated serum creatinine on at least two occasions, to ensure that renal impairment was longstanding. Due to the retrospective nature of the study, the absence of 24-hour urine volume data made it impossible to calculate creatinine clearance, for example, using the Cockcroft-Gault equation.…”

Impact of Femoropopliteal Bypass Surgery on the Survival and Amputation Rate of End-Stage Renal Disease Patients with Critical Limb Ischemia

“…The reason for this suggested differentiation is that we assume from our general clinical observations that gangrene with large tissue lost always causes a poorer survival than dry necrosis, regardless of whether the patients have been revascularized or not. However, this assumption is controversially debated in the literature, with some authors supporting it [8,9] and others not supporting it [2].…”

“…Georgopoulos et al [1] have found that the limb salvage rate in patients with ESRD and diabetes justifies limb revascularization, despite the decreased survival of this population. Treiman et al [2] stated that patients with impaired renal function are at increased risk for treatment failure due to potential impaired wound healing, but they nonetheless should not be denied revascularization surgeries, since the wounds may successfully heal. However, other investigators found that risk of death was higher after bypass surgery [3], especially after consecutive limb loss [4], and the risk of amputation increased depending on the procedure type and the diabetes status.…”