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

• 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

• 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

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

• Perioperative antibiotic prophylaxis
• Ready 2 packed red blood cells

• 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

• Epidural or general anesthesia
• Epidural catheter for postoperative analgesia recommended

• Supine
• Both arms abducted
• Possibly entire pelvis elevated by 5 cm
• Leave thigh and hip mobile, drape foot and knee

• Surgeon stands at affected side
• Assistant facing the surgeon
• Scrub nurse adjacent to assistant toward patient's feet

• Support for positioning the flexed knee (see figure)
• Amputation set
• Luer
• Drains
• Tourniquet only on stand-by
• Absorbable sutures 3-0 or 2-0 for vascular ligatures; skin sutures 3-0 or 4-0 or skin staples

Postoperative analgesia:

• Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current German guideline Behandlung akuter perioperativer and posttraumatischer Schmerzen [Treatment of acute perioperative and posttraumatic pain].
• Epidural catheter for postoperative analgesia recommended

Postoperative care

• Padded dressing of the stump (no compression!), comfortable positioning with the hip slightly flexed at 20–30°
• Remove drains after 24 hours if secretions are less than 50 ml

Deep venous thrombosis prophylaxis

• Guideline Prophylaxe der venösen Thromboembolie (VTE) (Prophylaxis in venous thromboembolism (VTE))
• Phenprocoumon or NOACs after 8–10 days at the earliest

Ambulation

• After 12 hours assisted sitting
• See physical therapy

Physical therapy

• After a few days, ambulation in walking frame with the wrapped residual limb without prosthesis
• Fit prosthesis after 4 to 6 weeks of primary wound healing
• Technical aids: Canes, walkers, 4-wheeled walkers, wheelchair, raised toilet seat

Diet

• 4-5 hours after surgery

Bowel movement

• Assist starting postoperative day 3, if needed

Work disability

• Most patients unable to work because of age and severity of illness