Perioperative management - Right-sided through-the-knee amputation in Fontaine stage IV peripheral arterial disease – Vascular Surgery - vascular surgery
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Indications
- Fontaine stage IV peripheral arterial disease (PAD) of the foot and distal lower leg
- If peripheral vascular reconstruction is not possible, transtibial amputation must have been ruled out and more distal amputation options exhausted
- Ideally, the deep femoral artery (DFA) should be patent, as otherwise healing of the femoral stump is at risk; possibly, reconstruction of the DFA should be attempted first
Classification of PAD according to Fontaine stage and Rutherford category
Fontaine stage
Presentation
Rutherford category
Grade
Presentation
I
Asymptomatic
0
0
Asymptomatic
IIa
Mild claudication (> 200 m)
1
I
Mild claudication
IIb
Moderate to severe claudication (< 200 m)
2
I
Moderate claudication
3
I
Severe claudication
III
Ischemic rest pain
4
II
Ischemic rest pain
IV
Ulceration or gangrene
5
III
Minor tissue loss
6
III
Major tissue loss
Contraindications
- General inoperability
- Amputation can be performed more distad
- Necrosis up to about one handbreadth inferior to the knee
- Massive infection of the lymphatic vessels in the lower leg
Preoperative diagnostic work-up
DSA
- Preoperative DSA mandatory to demonstrate local inoperability regarding revascularization
- No major amputation without angiography in PAD cases
- Possibly, transcutaneous pO2 measurement to determine the amputation level
Laboratory panels
- Complete blood count
- Electrolytes
- Kidney function parameters
- Coagulation
- Blood group
Resting ECG
Chest X-ray
Special preparation
- Perioperative antibiotic prophylaxis
- Ready 2 packed red blood cells
Informed consent
- Allergy/intolerance, e.g., to latex, drugs; acute cardiovascular response; intensive care measures; possibly permanent damage (e.g., organ failure, brain damage, paralysis)
- Secondary bleeding, hematoma, possibly reoperation
- Transfusion of allogeneic blood / blood components: risk of contracting hepatitis, HIV
- Skin, tissue and nerve damage due to positioning, measures accompanying the procedure (injections, disinfection, current); possibly long-term sequelae (pain, paralysis, inflammation, necrosis)
- Impaired wound healing, infection, osteitis, fistula formation; possibly reoperation, reamputation, sepsis
- Thrombosis/embolism
- Keloids, neuroma, phantom (limb) pain
- Functional impairment of the rstump, contralateral limb or spine due to incorrect weight bearing
Anesthesia
Positioning
Operating room setup
Special instruments and fixation systems
Postoperative management
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