CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 AFRICA 315 To take this one step further and minimise the risk of the study group being relatively small, operational planning should be regulated to maintain DFA patency. Lower-limb amputation per se is a procedure that increases metabolic load, and the higher the amputation level, the higher the energy usage.5 When the metabolic burden of underlying disease is also evaluated, surgery is the second impact. In addition, a meticulous approach is necessary to avoid the metabolic burden of infection, new tissue ischaemia and consecutive surgeries. In current studies, it has been stated that prosthetic graft infection requires a multidisciplinary approach and has serious consequences.6,7 For these reasons, it is important to prevent more destructive consequences by taking a multidisciplinary approach from the beginning in prosthetic graft patients without infection. Standard below- or above-knee amputations are and should be procedures with lower re-amputation rates compared with more distal amputations.3 Therefore, every effort should be made to make these approaches the ultimate treatment. Infection in the stump region, especially considering the underlying ischaemic condition, cannot be controlled without surgical debridement or conversion of the amputation level. In our study, the rate of conversion of the amputation level was statistically significantly lower for group B than for group A (p = 0.029). Transected, ligated and retracted prosthetic grafts can lead to colonisation and eventually infection (Fig. 1).8,9 As in our study, conditions such as a high number of co-morbidities, immune deficiency and ischaemia in the surgical field may cause delayed wound healing, infection and new ischaemic tissue loss in these patients.10 In our study, there were 12 wound-infection patients: nine in group A and three in group B. Eight of the nine patients in group A had positive wound cultures and needed surgical intervention. None of the three patients in group B had positive wound cultures or needed surgical intervention. These results were found to be statistically significant (p = 0.007). Probably the most imperative step of surgical planning in the CLI patient group is to achieve a viable and healable stump. This step is crucial to restoring the maximal amount of daily functioning. For this reason, the vascular supply of the remaining extremity should be meticulously evaluated before the procedure. The results of this study show that the excision of the entire prosthetic graft and the performance of saphenous patch-plasty in patients with a patent DFA were associated with better amputation results in these CLI patients. This can be interpreted in two different but related ways. First, pre-operative planning should be multidisciplinary in order to avoid undesirable medical, functional and economic results. Second, even though this is an extended procedure, it prevents the patient from undergoing multiple surgical and medical procedures with a higher metabolic load. Fig. 1. Two examples of partial graft-excision patients with infection. A. After debridement, total excision of the graft and VAC therapy, this patient ended up with hip disarticulation. B. The patient was managed with wound debridement, later, excision of the total graft, and VAC therapy. A B
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