CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 AFRICA 313 Prosthetic vascular graft management in above-knee amputations Levent Umur, Ismail Selçuk Abstract Objective: Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level. Methods: Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients (n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared. Results: Differences in growth of wound culture (p = 0.007), antibiotic duration (p = 0.003), hip disarticulation (p = 0.029) and duration of hospital stay (p = 0.0001) between the two groups were found to be statistically significant (p < 0.05). Conclusion: Management of CLI patients is a complex process, and a multidisciplinary approach is key to avoiding undesirable outcomes. Meticulous planning, including excision of the total graft, while ensuring the vascular supply, is essential. Keywords: critical limb ischaemia, above-knee amputation, prosthetic vascular graft, multidisciplinary approach Submitted 20/11/21, accepted 9/2/22 Published online 23/2/22 Cardiovasc J Afr 2022; 313–316 www.cvja.co.za DOI: 10.5830/CVJA-2022-012 Peripheral arterial disease (PAD) of the lower limb is a chronic problem that is associated with a large variety of symptoms from claudication to ischaemic tissue loss. Critical limb ischaemia (CLI) is the most severe state of PAD and is one of the major causes of lower-limb amputations.1 Treatment choices include conservative/pharmaceutical therapies, endovascular interventions, prosthetic or autogenous bypass graft surgeries, and amputation for end-stage disease.2 More than half of the surgical procedures are performed for femoropopliteal arteries. Despite vascular intervention, progression of the disease leads to lower-limb amputation in some patients. Since lower-limb amputation has catastrophic functional, social and economic outcomes, ascending conversion of the amputation level doubles or even triples these burdens, especially for above-knee amputation (AKA) patients.3 Therefore, a multidisciplinary approach that foresees and avoids further surgeries should be used for these patients. Wound infection and stump ischaemia are the main reasons for ascending conversion of the amputation level. For CLI patients with prosthetic grafts, these grafts can be a cause of infection after amputation. Pre-operational planning should be carried out meticulously to avoid further complications, such as excessive blood loss, graft infection and ischaemia. In this study, we aimed to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level. Methods Among 357 major limb amputations performed in our institution between 2016 and 2021, 63 patients who underwent AKA were retrospectively evaluated after approval by the institutional board. Forty-two patients with prosthetic grafts without underlying graft infection were included in this study. Before amputation, all patients were consulted with cardiovascular surgery for a decision on amputation level, and computerised tomographic angiography (CTA) was performed to evaluate the graft and vascular patency. In 24 of the 42 patients, a femoropopliteal bypass graft was ligated proximal to the amputation site, and AKA was performed with partial excision of the prosthetic graft (group A). In 18 patients (group B), in the same session with intra-operative cardiovascular surgery consultation, the entire prosthetic graft was excised via an additional incision made at the ipsilateral inguinal ligament level, by dissecting the artery from the proximal part of the graft, and AKA was performed. In nine patients in group B, in which patency of the deep femoral artery (DFA) was documented via CTA, additional saphenous vein patch-plasty was applied simultaneously to the common femoral artery, and for only these patients, the heparinisation protocol (maintaining the activated clotting time between 150 and 200 seconds) was carried on. The femoral artery was ligated in the rest of the group B patients. Postoperative wound discharge, growth of wound culture, antibiotic and vacuum-assisted closure (VAC) requirements, conversion to hip disarticulation, and hospitalisation periods of the patients were compared. Department of Orthopaedics and Traumatology, Acibadem Kadikoy Hospital, Istanbul, Turkey Levent Umur, MD, dr.flumur@gmail.com Department of Cardiovascular Surgery, Sultan Abdulhamid Han Teaching and Research Hospital, Istanbul, Turkey Ismail Selçuk, MD
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