Perioperative management - Right-sided through-the-knee amputation in Fontaine stage IV peripheral arterial disease – Vascular Surgery

  1. 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

     

  2. 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
  3. 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

  4. Special preparation

    • Perioperative antibiotic prophylaxis
    • Ready 2 packed red blood cells
  5. 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

Epidural or general anesthesiaEpidural catheter for postoperative analgesia recommended ... - Opera

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