Document Detail

Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization.
MedLine Citation:
PMID:  16828434     Owner:  NLM     Status:  MEDLINE    
OBJECTIVES: The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization.
METHODS: A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) <0.7 or a toe pressure <50 mm Hg. Patients were treated without revascularization when medical comorbidity or anatomic considerations did not allow revascularization with acceptable risk. Ulcers were treated with a protocol emphasizing pressure relief, débridement, infection control, and moist wound healing. Risk factors analyzed for their affect on healing and amputation risk included age, gender, diabetes mellitus, chronic renal insufficiency (serum creatinine > 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location.
RESULTS: Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation < or =6 months of initial treatment and 23% at 12 months. Complete wound closure was achieved in 25% by 6 months and in 52% by 12 months. Statistical analysis showed a correlation between ABI and the risk of limb loss. In patients with an ABI <0.5, 28% and 34% of limbs experienced limb loss at 6 and 12 months, respectively, compared with 10% and 15% of limbs in patients with an ABI >0.5 (P = .01). The only risk factor associated with wound closure was initial wound size (P < .005).
CONCLUSIONS: Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI <0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program.
William A Marston; Stephen W Davies; Brian Armstrong; Mark A Farber; Robert C Mendes; Joseph J Fulton; Blair A Keagy
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Journal of vascular surgery     Volume:  44     ISSN:  0741-5214     ISO Abbreviation:  J. Vasc. Surg.     Publication Date:  2006 Jul 
Date Detail:
Created Date:  2006-07-10     Completed Date:  2006-08-18     Revised Date:  2012-10-03    
Medline Journal Info:
Nlm Unique ID:  8407742     Medline TA:  J Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  108-114     Citation Subset:  IM    
Division of Vascular Surgery, Department of Surgery, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27599-7212, USA.
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MeSH Terms
Aged, 80 and over
Chronic Disease
Disease Progression
Ischemia / complications*
Leg / blood supply*
Leg Ulcer / etiology,  therapy*
Life Tables
Limb Salvage*
Middle Aged
Multivariate Analysis
Peripheral Vascular Diseases / therapy*
Retrospective Studies
Risk Factors
Wound Healing

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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