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Most research on people undergoing lower limb amputations for dysvascular disease summarizes average patient outcome risks and average associations between patient factors and these outcomes. More recently, the importance of predicting patient-specific outcomes based on individual factors (ie, personalized rehabilitation) has become evident. This article reviews the evidence and discusses the importance of the following: (1) predicting outcomes to facilitate amputation-level and prosthesis prescription decisions and (2) how prediction models can be leveraged to develop decision support tools to facilitate provider/patient shared decision-making to ensure decisions considering each individual patient's priorities and preferences. Examples of these tools are discussed and referenced., Competing Interests: Disclosure No authors have any commercial or financial conflicts of interest nor any funding sources to report at the time of this submission., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle., Methods: A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables., Results: Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042)., Conclusions: Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Lower extremity amputation continues to be necessary in a significant number of patients with peripheral vascular disease. The 5-year survival following lower limb loss is markedly reduced. Many of these patients are never fitted with a prosthesis, and there is a dearth of knowledge regarding the barriers to prosthetic attainment. The goal of this study was to identify the risk factors for not receiving a prosthesis and the effect of mobility level on survival following major amputation., Methods: This was a retrospective analysis of all patients that underwent lower extremity amputation by surgeons in our practice from January 1, 2010, to December 31, 2019. Abstracted data included: age, sex, race, body mass index, comorbidities, American Society of Anesthesiologists score, statin use, level of amputation, stump revision, fitting for prosthesis, type of prosthesis, and the United States' Medicare Functional Classification Level, also called K level. Survival was determined using a combination of sources, including the Social Security Death Master File, searches of multiple genealogic registries, and general internet searches. Multivariable logistic regression was used to determine risk factors associated with prosthesis attainment. Multivariable Cox proportional hazard regression with time-dependent covariates was performed to assess risk factors associated with 5-year mortality., Results: A total of 464 patients were included in this study. The mean age was 65 years, and mean body mass index was 27 kg/m 2 . The majority of patients were male (68%), White (56%), diabetic (62%), and hypertensive (76%), and underwent below-the-knee amputation (69%). Prosthetic attainment occurred in 185 (40%). On multivariable analysis, age >81 years and current tobacco use were associated with no prosthetic fitting. Overall 5-year survival was 41.9% (95% confidence interval [CI], 37.6%-46.6%) (below-the-knee amputation, 47.7% [95% CI, 42.5%-53.5%]; above-the-knee amputation, 28.7% [95% CI, 22.1%-37.2%]). On multivariable analysis, age >60 years, congestive heart failure, above-the-knee amputation, and no prosthetic attainment were associated with decreased survival. Increasing K level was incrementally associated with improved survival., Conclusions: This study has identified several patient factors associated with prosthetic attainment, as well as multiple factors predictive of reduced survival after amputation. Being referred for prosthetic fitting was associated with improved survival not explained by patient characteristics and comorbidities. The Medicare Functional Classification Level K level predicts survival. More research is needed to determine the barriers to prosthetic attainment and if improving a patients K level will improve survival., Competing Interests: Disclosures None., (Copyright © 2024 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention., Methods and Results: Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%)., Conclusions: Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.

Objectives: This study aimed to analyze the incidence, surgical management of major vascular complications, and outcomes in patients undergoing transfemoral (TF) transcatheter aortic valve replacement (TAVR) at our center after strict selection of the access route, carefully considering all known major predictors., Methods: Data of 494 consecutive patients with pre-interventional multi-slice computed tomography (CT) of the aorta who had undergone TF TAVR from 2009 to 2019 were analyzed., Results: In total, 23/494 (4.7%) patients had major vascular and access-related complications of peripheral vessels and/or infrarenal aorta. These included hematomas that met the Valve Academic Research Consortium 3-criteria of major vascular complications (7/494, 1.4%), arterial dissections (3/494, 0.6%), pseudoaneurysm (6/494, 1.2%), thrombus of the external iliac artery leading to acute limb ischemia (1/494, 0.2%), fistula (1/494, 0.2%), and perforation (5/494, 1.0%). In total, 17/23 (73.9%) major vascular complications required immediate endovascular and/or open surgery. In 16/17 (94%) cases, only 1 surgical procedure was performed. The long-term survival of patients with and without major vascular complications of the peripheral vessels was determined after 2 years., Conclusions: Early vascular surgery intervention reversed the mortality disadvantage in patients with major complications of the peripheral vessels after TAVR. This underscores the importance of immediate vascular surgery stand-by as an indispensable requirement., (Copyright © 2023 Hellenic Society of Cardiology. Published by Elsevier Inc. All rights reserved.)

Background: Acute limb ischemia (ALI) is an emergency vascular pathology in which perfusion is disrupted in the lower extremity and threatens extremity viability. The admission blood glucose (ABG)/estimated average glucose (eAG) value has recently been shown as a prognostic marker in acute cardiovascular events. In this study, we aimed to investigate the predictive role of an ABG/eAG value in predicting development of early postoperative major amputation after emergency thromboembolectomy operations in patients presenting with ALI., Method: Patients who admitted to our hospital with ALI between November 01, 2016 and September 01, 2021 and underwent surgical thromboembolectomy were retrospectively included in the study. Patients who did not undergo postoperative limb amputation were recorded as Group 1, and patients who underwent major amputation in the early postoperative period (in-hospital), were recorded as Group 2., Results: The median age of the 226 patients included in Group 1 and 72 patients in Group 2 were 58 (34-86) years and 69 (33-91) years, respectively ( p <0.001). In univariate analysis, in-hospital amputation was found to significantly correlate with age>70 years (odds ratio [OR]: 1.914, 95% confidence interval [CI]: 1.351-2.319, p <0.001), PAD (OR: 1.698, 95% CI: 1.270-1.992, p = 0.002 re-embolectomy (OR: 2.184, 95% CI: 1.663-3.085, p < 0.001), admission Rutherford class (OR: 0.762, 95% CI: 0.591-0.859, p = 0.032), admission time>6 h (OR: 1.770, 95% CI: 1.480-1.152, p = 0.009), ABG (OR: 1.275, 95% CI: 1.050-1.790, p < 0.001), and ABG/eAG (OR: 1.669, 95% CI: 1.315-2.239, p < 0.001)., Conclusion: According to our study, we can predict patient groups with a high risk of major amputation with the ABG/eAG value calculated from the blood values of the patients at the time of admission., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Periprosthetic fractures (PPFs) around the hip joint are increasing in prevalence. In this collaborative study, we aimed to investigate the impact of patient demographics, fracture characteristics, and modes of management on in-hospital mortality of PPFs involving the hip., Methods: Using a multi-centre cohort study design, we retrospectively identified adults presenting with a PPF around the hip over a 10-year period. Univariate and multivariable logistic regression analyses were performed to study the independent correlation between patient, fracture, and treatment factors on mortality., Results: A total of 1,109 patients were included. The in-hospital mortality rate was 5.3%. Multivariable analyses suggested that age, male sex, abbreviated mental test score (AMTS), pneumonia, renal failure, history of peripheral vascular disease (PVD) and deep surgical site infection were each independently associated with mortality. Each yearly increase in age independently correlates with a 7% increase in mortality (OR 1.07, p=0.019). The odds of mortality was 2.99 times higher for patients diagnosed with pneumonia during their hospital stay [OR 2.99 (95% CI 1.07-8.37) p=0.037], and 7.25 times higher for patients that developed renal failure during their stay [OR 7.25 (95% CI 1.85-28.47) p=0.005]. Patients with history of PVD have a six-fold greater mortality risk (OR 6.06, p=0.003). Mode of treatment was not a significant predictor of mortality., Conclusion: The in-hospital mortality rate of PPFs around the hip exceeds 5%. The fracture subtype and mode of management are not independent predictors of mortality, while patient factors such as age, AMTS, history of PVD, pneumonia, and renal failure can independently predict mortality. Peri-operative optimisation of modifiable risk factors such as lung and kidney function in patients with PPFs around the hip during their hospital stay is of utmost importance., Competing Interests: Declaration of Competing Interest A.M is the president of the British Trauma Society. The author(s) received no financial or material support for the research, authorship, and/or publication of this article., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Frailty is associated with adverse surgical outcomes including post-operative complications, needs for post-acute care, and mortality. While multiple frailty screening tools exist, most are time and resource intensive. Here we examine the association of an automated electronic frailty index (eFI), derived from routine data in the Electronic Health Record (EHR), with outcomes in vascular surgery patients undergoing open, lower extremity revascularization., Methods: A retrospective analysis at a single academic medical center from 2015 to 2019 was completed. Information extracted from the EHR included demographics, eFI, comorbidity, and procedure type. Frailty status was defined as fit (eFI≤0.10), pre-frail (0.100.21). Outcomes included length of stay (LOS), 30-day readmission, and non-home discharge., Results: We included 295 patients (mean age 65.9 years; 31% female), with the majority classified as pre-frail (57%) or frail (32%). Frail patients exhibited a higher degree of comorbidity and were more likely to be classified as American Society of Anesthesiologist class IV (frail: 46%, pre-frail: 27%, and fit: 18%, P = 0.0012). There were no statistically significant differences in procedure type, LOS, or 30-day readmissions based on eFI. Frail patients were more likely to expire in the hospital or be discharged to an acute care facility (31%) compared to pre-frail (14%) and fit patients (15%, P = 0.002). Adjusting for comorbidity, risk of non-home discharge was higher comparing frail to pre-frail patients (OR 3.01, 95% CI 1.40-6.48)., Discussion: Frail patients, based on eFI, undergoing elective, open, lower extremity revascularization were twice as likely to not be discharged home., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Patients with hepatitis C virus (HCV) undergoing primary elective total joint arthroplasty (TJA) are at increased risk of postoperative complications. Patients with chronic liver disease and cirrhosis, specifically Child-Pugh Class B and C, who are undergoing general surgery have high 2-year mortality risks, approaching 60% to 80%. However, the role of Child-Pugh and Model for End-Stage Liver Disease classifications of liver status in predicting survivorship among patients with HCV undergoing elective arthroplasty has not been elucidated., Question/purpose: What factors are independently associated with early mortality (< 2 years) in patients with HCV undergoing arthroplasty?, Methods: We performed a retrospective study at three tertiary academic medical centers and identified patients with HCV undergoing primary elective TJA between January 2005 and December 2019. Patients who underwent revision TJA and simultaneous primary TJA were excluded. A total of 226 patients were eligible for inclusion in the study. A further 25% (57) were excluded because they were lost to follow-up before the minimum study requirement of 2 years of follow-up or had incomplete datasets. After the inclusion and exclusion criteria were applied, the final cohort consisted of 75% (169 of 226) of the initial patient population eligible for analysis. The mean follow-up duration was 53 ± 29 months. We compared confounding variables for mortality between patients with early mortality (16 patients) and surviving patients (153 patients), including comorbidities, HCV and liver characteristics, HCV treatment, and postoperative medical and surgical complications. Patients with early postoperative mortality were more likely to have an associated advanced Child-Pugh classification and comorbidities including peripheral vascular disease, end-stage renal disease, heart failure, and chronic obstructive pulmonary disease. However, both groups had similar 90-day and 1-year medical complication risks including myocardial infarction, stroke, pulmonary embolism, and reoperations for periprosthetic joint infection and mechanical failure. A multivariable regression analysis was performed to identify independent factors associated with early mortality, incorporating all significant variables with p < 0.05 present in the univariate analysis., Results: After accounting for significant variables in the univariate analysis such as peripheral vascular disease, end-stage renal disease, heart failure, chronic obstructive pulmonary disease, and liver fibrosis staging, Child-Pugh Class B or C classification was found to be the sole factor independently associated with increased odds of early (within 2 years) mortality in patients with HCV undergoing elective TJA (adjusted odds ratio 29 [95% confidence interval 5 to 174]; p < 0.001). The risk of early mortality in patients with Child-Pugh Class B or C was 64% (seven of 11) compared with 6% (nine of 158) in patients with Child-Pugh Class A (p < 0.001)., Conclusion: Patients with HCV and a Child-Pugh Class B or C at the time of elective TJA had substantially increased odds of death, regardless of liver function, cirrhosis, age, Model for End-Stage Liver Disease level, HCV treatment, and viral load status. This is similar to the risk of early mortality observed in patients with chronic liver disease undergoing abdominal and cardiac surgery. Surgeons should avoid these major elective procedures in patients with Child-Pugh Class B or C whenever possible. For patients who feel their arthritic symptoms and pain are unbearable, surgeons need to be clear that the risk of death is considerably elevated., Level of Evidence: Level III, therapeutic study., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2023 by the Association of Bone and Joint Surgeons.)

The arteries of the lower limbs are innervated by vascular branches (VBs) originating from the lumbar sympathetic trunk and branches of the spinal nerve. Although lumbar sympathectomy is used to treat nonreconstructive critical lower limb ischemia (CLLI), it has limited long-term effects. In addition, the anatomical structure of tibial nerve (TN) VBs remain incompletely understood. This study aimed to clarify their anatomy and better inform the surgical approach for nonreconstructive CLLI. Thirty-six adult cadavers were dissected under surgical microscopy to observe the patterns and origin points of VBs under direct vision. The calves were anatomically divided into five equal segments, and the number of VB origin points found in each was expressed as a proportion of the total found in the whole calf. Immunofluorescence staining was used to identify the sympathetic nerve fibers of the VBs. Our results showed that the TN gave off 3-4 VBs to innervate the posterior tibial artery (PTA), and the distances between VBs origin points and the medial tibial condyle were: 24.7 ± 16.3 mm, 91.7 ± 66.1 mm, 199.6 ± 52.0 mm, 231.7 ± 38.5 mm, respectively. They were mainly located in the first (40.46%) and fourth (31.68%) calf segments, and immunofluorescence staining showed that they contained tyrosine hydroxylase-positive sympathetic nerve fibers. These findings indicate that the TN gives off VBs to innervate the PTA and that these contain sympathetic nerve fibers. Therefore, these VBs may need to be cut to surgically treat nonreconstructable CLLI., (© 2022 American Association of Clinical Anatomists and British Association of Clinical Anatomists.)

Objective: Endovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI., Methods: The Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year., Results: Urgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality., Conclusions: Endovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias., (Published by Elsevier Inc.)

Background: The acute occlusion of a peripheral bypass graft leads to acute limb ischemia (ALI) and threatens the viability of the limb if left untreated. The aim of the present study was to analyze the results of surgical and hybrid revascularization techniques for patients with ALI due to peripheral graft occlusions., Methods: A retrospective analysis of 102 patients undergoing treatment for ALI due to peripheral graft occlusion between 2002 and 2021 was carried out at a tertiary vascular center. Procedures were classified as surgical when only surgical techniques were used and as hybrid when surgical procedures were combined with endovascular techniques such as balloon or stent angioplasty or thrombolysis. Endpoints were primary and secondary patency and amputation-free survival after 1 and 3 years., Results: Of all patients, 67 met the inclusion criteria, 41 were treated surgically and 26 by hybrid procedures. There were no significant differences in the 30-day patency rate, 30-day amputation rate, and 30-day mortality. The 1- and 3-year primary patency rates were 41.4% and 29.2% overall, respectively; 45% and 32.1% in the surgical group, respectively; and 33.2% and 26.6% in the hybrid group, respectively. The 1- and 3-year secondary patency rates were 54.1% and 35.8% overall, respectively; 52.5% and 34.2% in the surgical group, respectively; and 54.4% and 43.5% in the hybrid group, respectively. The 1- and 3-year amputation-free survival rates were 67.5% and 59.2%, overall, respectively; 67.3% and 67.3% in the surgical group, respectively; and 68.5% and 48.2% in the hybrid group, respectively. There were no significant differences between the surgical and the hybrid groups., Conclusions: The results of surgical and hybrid procedures after bypass thrombectomy for ALI to eliminate the cause of infrainguinal bypass occlusion are comparable with good midterm results in terms of amputation-free survival. New endovascular techniques and devices need to be established in comparison to the results of these proven surgical revascularization methods., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Acute limb ischemia (ALI) is an emergency situation requiring rapid diagnosis and treatment. Although the traditional treating strategy for ALI includes open surgery, novel endovascular techniques have been introduced during the last decade. Additionally, many new cases of ALI have been reported due to infection by the SARS-CoV-2 virus. The aim of this study was to present an updated overview of characteristics, diagnosis, and current treating strategies of patients with ALI.

Background: Hybrid revascularization procedures for acute limb ischemia (ALI) are becoming increasingly common, bibliographic data on outcomes is however sparse., Methods: Single-center, retrospective study of consecutive patients with ALI that underwent either surgical treatment (ST) or hybrid treatment (HT) between January 2015 and December 2021. The composite outcome of amputation-free survival (AFS) was the primary endpoint. Technical success, overall survival, amputation, and re-intervention rates were the secondary endpoints., Results: During the study period 266 patients (mean age 70.2±14.5 years; 49.6% males) were treated for ALI, 67.3% undergoing ST and 32.7% HT. HT was more frequently used in patients with a previous vascular intervention in the index limb (38/87; 43.7% HT vs. 40/179; 22.3% ST, P=0.001), a stent- or stent graft-occlusion (16/87; 18.4% HT vs. 10/179; 5.6% ST, P=0.002) and/or a bypass occlusion (16/87; 18.4% HT vs. 16/179; 8.9% ST, P=0.043). Technical success was higher in the OR group (75/87; 86.2% HT vs. 173/179; 96.6% ST, P=0.003). Amputation-free survival rate during follow-up (43/87; 49.4% HT vs. 94/179; 52.5% ST, HR 0.76, 95% CI: 0.49 to 1.18, P=0.22) and overall survival (32/87; 36.8% HT vs. 84/179; 46.9% ST, HR 0.81, 95% CI: 0.49 to 1.34, P=0.41) were comparable between the two groups. No statistical differences were observed between the groups regarding major amputation (19/87; 21.8% HT vs. 15/179; 8.4% ST, HR 0.85, 95% CI: 0.33 to 2.23, P=0.74) or reintervention during follow-up (45/87; 51.7% HT vs. 65/179; 36.3% ST, HR 0.92, 95% CI: 0.56 to 1.51, P=0.73)., Conclusions: Hybrid and open surgical treatments showed comparable results in our cohort, even though significantly more patients undergoing HT presented with stent and bypass occlusions rather than de-novo lesions.

Acute limb ischemia still represents a challenge for the contemporary vascular surgeon, representing an immediate threat for patients' limb but potentially also for the proper patient life in some settings. Technology recently evolved and focused on the treatment of such complex situation. Several devices are available as of today allowing a complete acute limb ischemia endovascular management, aiming to remove intraluminal material while leaving the possibility for treating the underlying pathology when needed. In this review, proper specific device characteristics, indications and advantages are reported and discussed. Despite the broad spectrum of different available devices could appear as potentially confounding, each device has its own features, indications, weak and strength point. Ideally the modern endovascular surgeon should master every single tool, tailoring revascularization strategy and timing for the proper patient and arterial segment to be treated, maximizing the benefits coming from technological improvements.

Objectives: The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE)., Methods: This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis., Results: Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p -value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p -value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p -value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p -value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p -value < .001) and bypass (2.6% vs 22.7%, p -value = .01)., Conclusion: ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Background: No consensus has yet been reached regarding the optimal treatment of patients with thromboangiitis obliterans (TO) and chronic limb ischemia. In the present study, we aimed to summarize the results on endovascular treatment of such patients., Methods: We performed a meta-analysis using the following databases: PubMed, Scopus, and the Cochrane Library. The eligible studies had been reported up to December 2021 and had evaluated endovascular angioplasty to treat patients with TO and chronic limb ischemia. The early (mortality and technical success) and late (primary/secondary patency and limb salvage) outcomes were evaluated. StatsDirect (StatsDirect Ltd, Merseyside, UK) was used for the statistical analysis., Results: Overall, 15 eligible studies were included (only endovascular in 11 studies and both endovascular and open repair in 4 studies). Among 601 patients, 402 endovascular procedures (416 limbs) were recorded (angioplasty plus stenting for 7.2% and angioplasty plus thrombolysis for 3.7%). The clinical presentation was intermittent claudication (stage II-III) for 7.9% of the patients and critical ischemia (stage IV-VI) for 92.1% of the patients. Most of the patients had had lesions below the knee, and five had had upper extremity lesions. The pooled technical success rate was 86% (range, 81.1%-90.3%), with no in-hospital mortality. The other complications included perforations (1.9%), wound complications (2.2%), and distal embolism (0.2%). Primary patency was 65.7% (range, 52.7%-77.6%) at 12 months and 50.7% (range, 23.3%-77.9%) at 36 months. Secondary patency was 76.2% (range, 57.5%-90.8%) at 12 months and 64.5% (range, 32.3%-90.6%) at 36 months. The limb salvage rate was 94.1% (range, 90.7%-96.7%) at 12 months and 89.1% (range, 80.6%-95.4%) at 36 months., Conclusions: Endovascular angioplasty for patients with TO and chronic limb ischemia was associated with optimal safety and low complication rates. The technical success and late outcomes were acceptable., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: To determine the outcome of children treated for acute limb ischemia (ALI) in pediatric intensive care units (ICUs)., Methods: A single-center, retrospective cohort study including all patients diagnosed with ALI between 2005 and 2022 in 2 different pediatric ICUs: respiratory and cardiac ICU. Data collected included patients demographics and comorbidities, location and cause of arterial occlusion, and type and duration of therapy. Primary end point was freedom from amputation. Secondary end point was all-cause mortality., Results: A total of 78 patients (58% male) with ALI were included in the study. Median age was 3.8 months (range 0.03-201). The lower extremity was involved in 55 (70%) patients. The limb ischemia was caused by arterial instrumentation in 94% of the patients. Anticoagulation was administered as the first-line therapy in all patients. Unfractionated heparin was administered for a median duration of 5 days (range 1-48). Low molecular weight heparin was continued for a median period of 28 days (range 4-420). Thrombolytic therapy was administered in 5 patients and 2 required surgical revascularization, all for failure of anticoagulation therapy. Mean follow-up was 21 months (range 1-188 months). None of the patients required major upper or lower extremity amputations during or after the index admission. Overall survival at 30 months was 68%. The causes of mortalities were unrelated to the limb ischemia., Conclusions: This large, single-center study demonstrates that ALI in the pediatric ICU population can be treated conservatively and is associated with a low amputation rate following nonoperative management. The favorable outcome exists regardless of the etiology of the ALI and underlying diseases., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection., Methods: During the 2 years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30 days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes., Results: Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P = 0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P < 0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P = 0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P = 0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P = 0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P = 0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P = 0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P = 0.04; no differences in other secondary outcomes were observed between the groups., Conclusions: Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To analyze the results of redo reconstructions of lower limb arteries in patients with obliterating atherosclerosis, immediate and long-term results in patients who underwent reconstructive interventions with occlusion of previous reconstruction and preventive interventions., Material and Methods: The study included 43 patients. The main group (group 1) consisted of 18 patients who underwent preventive vascular reconstructions. The control group enrolled 25 patients who underwent redo interventions for occlusion of previous reconstructions. The control group was divided into 2 parts; 15 patients had chronic limb ischemia (group 2), 10 patients had acute limb ischemia (group 3). Mean age of patients was 56.8±8.2 years; there were 37 (86%) men and 6 (14%) women. Multifocal vascular atherosclerosis was noted in 41 (95.3%) patients, carotid artery lesion - 29 (70.7%), coronary artery disease - 34 (79%). Patients with type II diabetes mellitus were excluded., Results: We chose each surgical intervention considering preoperative diagnostic data. Open, endovascular and hybrid interventions were performed. There were no deaths and limb amputations in the 1 st group. Two (13.3%) amputations were registered in the 2 nd group, 3 (30%) amputations and 1 (10%) death were registered in the 3 rd group. The follow-up period was 24 months. An 18-month freedom from amputations was 71.5%, 78% and 38%, respectively ( p <0.05 compared to the 1 st and 2 nd groups)., Conclusion: Preventive surgical interventions prevent ischemia and amputation, as well as improves the results of redo surgery.

Background: Knowledge of diagnosis and treatment of acute limb ischemia is essential to preserve limb viability and prevent irreversible damage., Objective: A brief review of treatment options, patient selection, and management in acute limb ischemia is provided for residents in interventional radiology., Methods: The most commonly used interventional treatment options in acute limb ischemia including case studies and recommendations are provided., Results: In acute limb ischemia, the decision between therapeutic procedures (interventional or surgical) depends on the clinical stage. There are three main interventional procedures: catheter-directed thrombolysis, thromboaspiration, and mechanical thrombectomy using specialized catheters; a combination of these procedures is also possible. The decision depends on various factors, some of which are center-specific, and should therefore always be made by interdisciplinary consensus. After near-complete revascularization, the cause should be sought and eliminated., Conclusions: In a case of suspected acute limb ischemia, patients should ideally be taken to an interdisciplinary center with interventional radiology and vascular surgery. After clinical evaluation and noninvasive imaging, a decision regarding possible therapeutic options can be made., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: To provide information on the outcomes of upper and lower limb surgical embolectomies and the factors influencing amputation and mortality., Methods: A retrospective, single-center analysis of 347 patients (female, N = 207; male, N = 140; median age, 76 years [interquartile range {IQR}, 63.2-82.6 years]) with acute upper or lower limb ischemia due to thromboembolism who underwent surgery between 2005 and 2019 was carried out. Patient demographics, comorbidities, medical history, the severity of acute limb ischemia (ALI), preoperative medication regimen, embolus/thrombus localization, procedural data, in-hospital complications/adverse events and their related interventions, and 30-day mortality were reviewed in electronic medical records. Statistical analysis was performed using the Mann-Whitney U test and Fisher's exact test; in addition, univariate and multivariate logistic regression was conducted., Results: The embolus/thrombus was localized to the upper limb in 134 patients (38.6%) and the lower limb in 213 patients (61.4%). The median length of hospital stay was 3.8 days (IQR, 2.1-6.6 days). The in-hospital major amputation rates for the upper limb, lower limb, and total patient population were 2.2%, 14.1%, and 9.5%, respectively, and the in-hospital plus 30-day mortality rates were 4.5%, 9.4%, and 7.5%, respectively. In patients with lower limb embolectomy, the predictor of in-hospital major amputation was the time between the onset of symptoms and embolectomy (OR, 1.78), while the predictor of in-hospital plus 30-day mortality was previous stroke (OR, 7.16). In the overall patient cohort, there were two predictors of in-hospital major amputation: 1) the time between the onset of symptoms and embolectomy (OR, 1.92) and 2) compartment syndrome (OR, 3.51)., Conclusion: Amputation and mortality rates after surgical embolectomies in patients with ALI are high. Patients with prolonged admission time, compartment syndrome, and history of stroke are at increased risk of limb loss or death. To avoid amputation and death, patients with ALI should undergo surgical intervention as soon as possible and receive close monitoring in the peri- and postprocedural periods., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2022 Bérczi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Few studies have focused on arterial thrombosis and acute limb ischemia in COVID-19. This international registry intended to study the spectrum of clinical characteristics, therapeutic trends, and outcomes in a cohort of Ibero-Latin American patients with arterial thrombosis or acute limb ischemia and COVID-19., Methods: Data were retrospectively obtained from 21 centers in 9 countries. Patients with proven COVID-19 and asymptomatic or symptomatic arterial thrombosis were included. COVID-19 diagnosis was established by RT-PCR assay or IgM serology plus suggestive clinical/radiographical findings. We recorded and analyzed variables related to demography, clinical presentation, therapeutic trends, and outcomes., Results: Eighty one patients were included in the registry. In 38.3%, acute limb ischemia symptoms were the first manifestation of COVID-19. Non-surgical management was more frequent in severe cases than surgical interventions, 11.1% vs. 88.9%, respectively ( p = 0.004). Amputation rates were similar between all COVID severity groups ( p = 0.807). Treatment was classified as non-surgical, open surgical, and endovascular treatment. Further analysis revealed an equal frequency of major leg amputation between treatment groups and increased mortality in patients with non-surgical management. However, multivariate regression analysis showed that treatment choices are associated with disease severity, with significant non-surgical treatment in critical patients; thus, mortality is related to the severity and confounds treatment analysis., Conclusion: Arterial thrombosis can be the initial symptom of a patient presenting with COVID-19. Physicians and health workers should potentially suspect COVID-19 in acute ischemia cases without a known risk factor or embolic cause. More experimental and clinical research is required to understand the complex phenomenon of arterial COVID-19 induced coagulopathy fully.

Background: An infection-resistant, immediately available conduit for trauma and urgent vascular reconstruction remains a critical need for successful limb salvage. While autologous vein remains the gold standard, vein-limited patients and size mismatch are common issues. The Human Acellular Vessel (HAV) (Humacyte, Inc., Durham, NC) is a bioengineered conduit with off-the-shelf availability and resistance to infection, ideal characteristics for patients with challenging revascularization scenarios. This report describes HAV implantation in patients with complex limb-threatening ischemia and limited conduit options who may have otherwise faced limb loss., Methods: The Food and Drug Administration (FDA) expanded-access program was used to allow urgent implantation of the HAV for arterial reconstruction. Electronic medical records were reviewed with extraction of relevant data including patient demographics, surgical implantation, patency, infectious complications, and mortality., Results: The HAV was implanted in 8 patients requiring vascular reconstruction. Graft or soft tissue infection was present in 2 patients. One patient with severe penetrating pelvic injury had 4 HAV placed to repair bilateral external iliac artery and vein injuries. There was 1 technical failure due to poor outflow, 2 patients died unrelated to HAV use, and 5 lower extremity bypasses maintained patency at an average of 11.4 months (range: 4-20 months). No HAV infectious complications were identified., Conclusions: This report is the first United States series describing early outcomes using the HAV under the FDA expanded-access program for urgent vascular reconstruction. The HAV demonstrates resistance to infection, reliable patency, and offers surgeons an immediate option when confronted with complex revascularization scenarios. Assessment of long-term outcomes will be important for future studies., (Published by Elsevier Inc.)

Purpose: The majority of lower extremity amputations (LEAs) are the result of diabetes or peripheral vascular disease. There is a paucity of literature on individuals' experiences living with dysvascular LEAs in the community, particularly in Canada. The purpose of this study was to explore the perceptions and experiences of community-dwelling adults living with dysvascular LEA., Methods: Semi-structured qualitative interviews were conducted with individuals with a dysvascular LEA recruited from three rehabilitation hospitals. Participants were included if they were English-speaking adults at least three months post-amputation and no longer receiving inpatient rehabilitation. Sampling was purposive to ensure variation by gender, level of amputation, and geographic location. Data were analyzed using an inductive content-analysis approach., Results: Thirty-five interviews were completed with individuals with dysvascular LEA. Study participants portrayed LEA as having an impact on many aspects of their lives, resulting in changes in their mobility, social activities and roles, and psychological wellbeing. Three main factors shaped individuals' experiences with dysvascular LEA including social support, accessibility, and socioeconomic factors., Conclusion: Our findings highlight the impacts of dysvascular LEA in peoples' lives. Future research is warranted to explore how community-based interventions and strategies can address the ongoing needs of individuals with dysvascular LEA.Implications for rehabilitationOur findings highlight the long-term impacts of dysvascular lower extremity amputations, which resulted in changes in mobility, social activities and roles, and psychological wellbeing.Participants identified issues in access to community services and resources, including rehabilitation.Mechanisms to identify people at risk for social isolation need to be developed and implemented in rehabilitation centers.Access to ongoing rehabilitation services in the community are needed to optimize mobility outcomes and address ongoing psychological needs.

Background: Acute lower limb ischemia (ALI) is limb and life-threatening. The aim of this study was to explore the association between adherence to guidelines on clinical diagnosis of ALI and outcome at 1 year. The hypothesis was that that better examination was associated with favorable outcome in ALI patients., Methods: Retrospective cohort study between 2015 and 2018. In-hospital, operation, radiological and autopsy registries captured 161 citizens of Malmö with ALI. The initial bedside evaluation was performed by an emergency physician. Scoring was based on evaluation of the 6 "Ps" and 1 point was given for pain, pallor, pulselessness, perishing cold, paresthesia, paralysis or ankle-brachial pressure index (ABI). The performance was scored (range 0-7), and a score ≥5 was defined as a satisfactory vascular leg status. A multivariate logistic regression was performed to adjust for confounders and expressed in Odds Ratios (OR) with 95% confidence intervals (CI)., Results: A satisfactory first clinical examination was performed in 55.3% of the patients. Measurement of ABI (OR 0.25, 95% CI 0.11-0.55), performing complete pulse status (OR 0.41, 95% CI 0.20-0.85), evaluating paralysis (OR 0.43, 95% CI 0.20-0.89), and a bedside score ≥5 points (OR 0.48, 95% CI 0.23-0.97) were independently associated with reduced risk of major amputation/mortality at 1-year follow up., Conclusions: Quality of initial bedside evaluation in patients with ALI was unsatisfactory to a large extent and better clinical examinations were associated with favorable outcome at 1 year. Skills in clinical diagnostics in ALI needs to be much improved., (Copyright © 2021. Published by Elsevier Inc.)

Background: Transtibial amputation (TTA) due to complications of diabetic foot infection (DFI) or peripheral vascular disease (PVD) is a high-risk procedure in fragile patients. The risks of reoperation, blood loss requiring blood transfusion, and mortality are high. The use of a tourniquet in this procedure is controversial and scarcely reported. Objective: this study aimed to compare the outcomes of TTAs with or without a tourniquet in a single tertiary medical center. Methods: We retrospectively identified all patients who had undergone TTA in our institution (1/2019-1/2020) and included only those who underwent the procedure due to complications of DFI or PVD ( n = 69). The retrieved data included demographics, comorbidities, ASA score, the use of a tourniquet, operation duration, pre- and postoperative hemoglobin levels, administration of blood transfusions, hospitalization length, surgical site infection and 60-days reoperation and mortality rates. Results: TTA with a tourniquet was superior to TTA without a tourniquet in reducing the average operation length by 11 min ( p = 0.05), the median postoperative hospitalization by 6 days ( p = 0.04), and the use of blood transfusions (odds ratio [OR] = 0.176, 95% confidence interval [CI]: 0.031-0.996). Conclusions: Our findings demonstrated advantages in operative time, hospitalization length, and blood transfusion requirement for TTA with a tourniquet compared to TTA without a tourniquet.

Background: For same-day discharge lower extremity arterial disease (LEAD) endovascular procedures, femoral manual compression could be an alternative to arterial closure devices. The aim of this study was to assess the security and efficacy of same-day discharge after manual compression in patients treated for LEAD endovascular revascularization with 5F sheath., Methods: FREEDOM OP was a national multicenter, prospective, single arm study. Patients with symptomatic LEAD (Rutherford 2-5) and eligible for same-day discharge were included. The primary endpoint was the total in-hospital admission rate, which includes overnight surveillance and rehospitalization rate at 1 month., Results: Between September 2017 and August 2019, 114 patients were included. The mean age of the patients was 66 ± 10 years and most of them were claudicant (103; 94%). Mainly femoropopliteal lesions were treated (178; 70%) and the technical success was 97%. One hundred forty-two 5F stents and fifty one 5F drug coated balloon were delivered. The mean manual compression duration was 13 ± 4 min. Major access-related complications rate was 4.5%. Total in-hospital admission rate was 11%. Seven patients had overnight surveillance and 5 were rehospitalized (2 for the target lesion). No rehospitalisation was carried out within 24 hr after discharge. No major cardiovascular event, including death, was observed. The patients were significantly improved in term of clinical status (P < 0.0001) and hemodynamic (P < 0.0001) in comparison to baseline., Conclusion: FREEDOM OP showed that manual compression is feasible and safe for same-day discharge after LEAD revascularization with 5F sheath femoral approach., (Copyright © 2021. Published by Elsevier Inc.)

Background: Intravascular ultrasound (IVUS) may be a useful adjunct to lower extremity peripheral vascular interventions (PVI) in certain clinical scenarios. We aimed to identify patient- and physician-level characteristics associated with the use of IVUS during first-time femoropopliteal PVI., Methods: We included all Medicare beneficiaries undergoing elective femoropopliteal PVI for claudication or chronic limb-threatening ischemia between 01/01/2019 and 12/31/2019. We excluded patients with prior open or endovascular femoropopliteal intervention and all physicians performing ≤10 PVI during the study period. We calculated the proportion of patients who had IVUS performed as part of their index PVI for each physician. Hierarchical logistic regression was used to evaluate patient- and physician-level factors associated with use of IVUS., Results: We identified 58,552 patients who underwent index femoropopliteal PVI, of whom 11,394 (19%) received IVUS. A total of 1,628 physicians performed >10 procedures during the study period, with IVUS utilization ranging from 0-100%. After hierarchical regression, claudication (versus chronic limb-threatening ischemia: OR 1.23, 95% CI 1.11-1.36), stenting (versus angioplasty alone: OR 1.57, 1.33-1.86) and atherectomy (versus angioplasty alone: OR 2.09, 1.83-2.39) were associated with higher odds of IVUS utilization. Higher-volume providers (tertile 3 vs. tertile 1: OR 3.78, 2.43-5.90) and those with high rates of service provided in an office-based laboratory (tertile 3 vs. tertile 1: OR 10.72, 6.78-19.93) were more likely to utilize IVUS. Radiologists (OR 11.23, 5.96-21.17) and cardiologists (OR 1.97, 1.32-2.93) used IVUS more frequently than vascular surgeons., Conclusions: Wide variability exists in the use of IVUS for first-time femoropopliteal PVI. The association of IVUS with claudication, atherectomy, and office-based laboratories raises concern about its potential overuse by some physicians., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Superficial femoral artery and profunda patency has been shown to affect aortofemoral bypass (AFB) limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis., Methods: Institutional AFB data from 2000 to 2017 were gathered, excluding that where Superficial femoral artery /EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency; cox proportional-hazards model evaluated EIA patency while controlling for other factors., Results: Over the study period, there were AFB 557 limbs in 281 patients. Of the 435 AFB limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6 ± 9.0. EIA occlusions were more common in male patients (59.9% vs. 44.6%; P = 0.001), patients with CAD (43.8% vs. 34.1%; P = 0.042), COPD (34.6% vs. 20.5%; P = 0.001), and CHF (14.8% vs. 5.9%; P = 0.002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs. 24.2%; P < 0.001) and simultaneous infrainguinal bypass (7.4% vs. 0.7%; P < 0.001). Median clinical follow-up was 4.4 years (IQR: 1.6-8.4). Five-year primary patency was 83.1% (95% CI: 74.5-90.0%) for EIA occlusion limbs and 85.9% (95% CI: 80.2-90.0%) with patent EIA limbs (P = 0.96). While controlling for other factors, EIA stenosis or occlusion did not affect primary patency. For patients with a proximal occlusion (occluded aorta, occluded common iliac, or end-to-end proximal anastomosis) and occluded SFA (N = 73), EIA occlusion had a HR of 1.92 for loss of patency, but this was not statistically significant., Conclusions: EIA patency did not influence primary patency in the overall cohort Further investigation on the topic in specific patient subgroups is warranted to determine the effect of EIA patency., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve replacement is an established treatment option for patients with severe symptomatic aortic stenosis and is most commonly performed through the transfemoral access route. Percutaneous access site closure can be achieved using dedicated plug-based or suture-based vascular closure device (VCD) strategies, but randomized comparative studies are scarce., Methods: The CHOICE-CLOSURE trial (Randomized Comparison of Catheter-based Strategies for Interventional Access Site Closure during Transfemoral Transcatheter Aortic Valve Implantation) is an investigator-initiated, multicenter study, in which patients undergoing transfemoral transcatheter aortic valve replacement were randomly assigned to vascular access site closure using either a pure plug-based technique (MANTA, Teleflex) with no additional VCDs or a primary suture-based technique (ProGlide, Abbott Vascular) potentially complemented by a small plug. The primary end point consisted of access site- or access-related major and minor vascular complications during index hospitalization, defined according to the Valve Academic Research Consortium-2 criteria. Secondary end points included the rate of access site- or access-related bleeding, VCD failure, and time to hemostasis., Results: A total of 516 patients were included and randomly assigned. The mean age of the study population was 80.5±6.1 years, 55.4% were male, 7.6% of patients had peripheral vascular disease, and the mean Society of Thoracic Surgeons score was 4.1±2.9%. The primary end point occurred in 19.4% (50/258) of the pure plug-based group and 12.0% (31/258) of the primary suture-based group (relative risk, 1.61 [95% CI, 1.07-2.44], P =0.029). Access site- or access-related bleeding occurred in 11.6% versus 7.4% (relative risk, 1.58 [95%CI: 0.91-2.73], P =0.133) and device failure in 4.7% versus 5.4% (relative risk, 0.86, [95% CI, 0.40-1.82], P =0.841) in the respective groups. Time to hemostasis was significantly shorter in the pure plug-based group (80 [32-180] versus 240 [174-316] seconds, P <0.001)., Conclusions: Among patients treated with transfemoral transcatheter aortic valve replacement, a pure plug-based vascular closure technique using the MANTA VCD is associated with a higher rate of access site- or access-related vascular complications but a shorter time to hemostasis compared with a primary suture-based technique using the ProGlide VCD. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04459208.

Background: Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation., Objectives: To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation., Search Methods: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies., Selection Criteria: Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival., Data Collection and Analysis: Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach., Main Results: We did not identify RCTs that met the inclusion criteria for this review., Authors' Conclusions: No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The contemporary scope of practice of interventional cardiologists (ICs) in the United States and recent trends are unknown. Using Medicare claims from 2013 to 2017, we categorized ICs into 4 practice categories (only percutaneous coronary intervention [PCI], PCI with noninvasive imaging, PCI with specialized interventions [peripheral/structural], and all 3 services) and evaluated associations with region, hospital bed size and teaching status, gender, and graduation year. Of 6,083 ICs in 2017, 10.9% performed only PCI, 68.3% PCI with noninvasive imaging, 5.7% PCI with specialized interventions, and 15.1% all 3 services. A higher proportion of Northeast ICs (vs South ICs) were performing only PCI (24.8% vs 7.3%) and PCI with specialized interventions (12% vs 3.4%), but lower PCI and noninvasive imaging (53.8% vs 71.7%) and all 3 services (9.3% and 17.6%). Regarding ICs at larger hospitals (bed size >575 vs <218), a higher proportion was performing only PCI (23.8% vs 5.2%) or PCI with specialized interventions (13.5% vs 1.7%) and lower proportion was performing PCI with noninvasive imaging (48.8% vs 78%), similar to teaching hospitals. Female ICs (vs male ICs) more frequently performed only PCI (18.9% vs 10.6%) and less frequently all 3 services (8.3% vs 15.4%). A lower proportion of recent graduates (2001 to 2016) performed only PCI (9.8% vs 13.8%) and PCI with noninvasive imaging (66.3% vs 72.6%) but a higher proportion performed all 3 services (18% vs 8.4%) than earlier graduates (1959 to 1984). From 2013 to 2017, only PCI and PCI with noninvasive imaging decreased, whereas PCI and specialized interventions and all 3 services increased (all p <0.001). In conclusion, there is marked heterogeneity in practice responsibilities among ICs, which has implications for training and competency assessments., Competing Interests: Disclosures Dr. Krumholz reported that he has contracts through Yale New Haven Hospital with the Centers for Medicare & Medicaid Services to support quality measurement programs and through Yale with UnitedHealth Group to engage in collaborative research. He was a recipient of a research grant, through Yale, from Medtronic for data sharing; from the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices; from Johnson & Johnson to support data sharing; and from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion. He is an advisor to the National Center for Cardiovascular Diseases in Beijing, was an expert witness for the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation, and is an expert witness for the Martin/Baughman Law Firm for work related to the Cook Celect IVC filter litigation and to the C.R. Bard Recovery IVC filter litigation and for the Siegfried and Jensen Law Firm for work related to the Vioxx litigation. He chairs a cardiac scientific advisory board for UnitedHealth; was a member of the IBM Watson Health Life Sciences Board; and is a member of the advisory board for Element Science, the healthcare advisory board for Facebook, and the physician advisory board for Aetna. He is the cofounder of HugoHealth, a personal health information platform, and cofounder of Refactor Health, an enterprise health care artificial intelligence–augmented data management company. He is a venture partner at F-Prime. Dr. Murugiah is supported by contracts through Yale New Haven Hospital with the Centers for Medicare & Medicaid Services to support quality measurement programs. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage., Methods: By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort., Results: We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001)., Conclusion: Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage., Competing Interests: Declaration of Competing Interest The authors have nothing to disclose. No funding was received for this article. Christoph Hirche has been a speaker for KCI and is on the Advisory Board for KCI Europe, Wiesbaden. Valentin Haug and Martin Kauke are recipients of the German Research Foundation Grant. The aforementioned sponsors have had no involvement in this study., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Surgical treatment of peripheral vascular malformations is widely performed as primary and secondary treatments. Excellent results have been reported; however, it is thought that complications are likely to occur because of damage to adjacent structures. This systematic review aimed to elucidate the indications and outcomes of surgical treatment of vascular malformations., Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies reporting outcomes of surgery in at least 15 patients with a single type of peripheral soft-tissue vascular malformation. The authors extracted data on patient and lesion characteristics, treatment characteristics, and outcomes (including complications). Meta-analysis was conducted on recurrence and complication rates., Results: A total of 3042 articles were found, of which 24 were included: nine studies on arteriovenous malformations, seven on venous malformations, and eight on lymphatic malformations, totaling 980 patients. Meta-analyses showed pooled proportions for recurrences of 11 percent in arteriovenous malformations, 5 percent in venous malformations, and 9 percent in lymphatic malformations. Pooled proportions of major complications were 9 percent for arteriovenous malformations, 3 percent for venous malformations, and 1 percent for lymphatic malformations. The authors found a 5 percent pooled recurrence proportion in total resections, compared with 28 percent in subtotal resections. The pooled odds ratio for recurrence in total and subtotal resections showed a significant lower recurrence rate after total resection (odds ratio, 0.14, p = 0.02)., Conclusions: Surgical treatment of vascular malformations appears to be effective and safe in many cases. However, it seems that surgery is performed predominantly in small lesions, and subtotal resection has a higher risk of recurrence than total resection., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Objective: Endovascular procedures are conventionally conducted using two dimensional fluoroscopy. A new technology platform, Fiber Optic RealShape (FORS), has recently been introduced allowing real time, three dimensional visualisation of endovascular devices using fiberoptic technology. It functions as an add on to conventional fluoroscopy and may facilitate endovascular procedures. This first in human study assessed the feasibility of FORS in clinical practice., Methods: A prospective cohort feasibility study was performed between July and December 2018. Patients undergoing (regular or complex) endovascular aortic repair (EVAR) or endovascular peripheral lesion repair (EVPLR) were recruited. FORS guidance was used exclusively during navigational tasks such as target vessel catheterisation or crossing of stenotic lesions. Three types of FORS enabled devices were available: a flexible guidewire, a Cobra-2 catheter, and a Berenstein catheter. Devices were chosen at the physician's discretion and could comprise any combination of FORS and non-FORS devices. The primary study endpoint was technical success of the navigational tasks using FORS enabled devices. Secondary study endpoints were user experience and fluoroscopy time., Results: The study enrolled 22 patients: 14 EVAR and eight EVPLR patients. Owing to a technical issue during start up, the FORS system could not be used in one EVAR. The remaining 21 procedures proceeded without device or technology related complications and involved 66 navigational tasks. In 60 tasks (90.9%), technical success was achieved using at least one FORS enabled device. Users rated FORS based image guidance "better than standard guidance" in 16 of 21 and "equal to standard guidance" in five of 21 procedures. Fluoroscopy time ranged from 0.0 to 52.2 min. Several tasks were completed without or with only minimal X-ray use., Conclusion: Real time navigation using FORS technology is safe and feasible in abdominal and peripheral endovascular procedures. FORS has the potential to improve intra-operative image guidance. Comparative studies are needed to assess these benefits and potential radiation reduction., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Ulnar artery revascularization in hypothenar hammer syndrome has repeatedly been shown to reduce ischaemic symptoms, however with varying graft patency percentages. This study prospectively assesses the effect of revascularization surgery with a vein graft using validated questionnaires in seven patients. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Cold Intolerance Symptom Severity (CISS) questionnaires have been used to compare the preoperative and postoperative functionality and cold intolerance. All patients showed improvement in either functionality, or cold intolerance, or both from disabled to nearly normalized levels and resumed their occupation at final follow-up (mean of 28 months). Strikingly this was also the case in a patient with graft stenosis. Patients with the highest preoperative questionnaire scores showed most postoperative improvement. In conclusion, revascularization surgery seems to improve the symptomatology irrespective of graft patency. Questionnaires can be a valuable contribution to quantify and to follow the symptomatology in hypothenar hammer syndrome., Competing Interests: Declaration of Competing Interest The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (Copyright © 2020 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed., Methods: A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality., Results: A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results., Conclusions: Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Every year, thousands of patients with peripheral vascular disease undergo major lower limb amputation. Despite this, evidence for optimal management is weak. Core outcome sets capture consensus on the most important outcomes for a patient group to improve the consistency and quality of research. The aim was to define short and medium term core outcome sets for studies involving patients undergoing major lower limb amputation., Methods: A systematic review of the literature and focus groups involving patients, carers, and healthcare professionals were used to derive a list of potential outcomes. Findings informed a three round online Delphi consensus process, where outcomes were rated for both short and medium term studies. The results of the Delphi process were discussed at a face to face consensus meeting, and recommendations were made for each core outcome set., Results: A systematic review revealed 45 themes to carry forward to the consensus survey. These were supplemented by a further five from focus groups. The consensus survey received responses from 123 participants in round one, and 91 individuals completed all three rounds. In the final round, nine outcomes were rated as "core" for short term studies and a further nine for medium term studies. Wound infection and healing were rated as "core" for both short and medium term studies. Outcomes related to mortality, quality of life, communication, and additional healthcare needs were also rated as "core" for short term studies. In medium term studies, outcomes related to quality of life, mobility, and social integration/independence were rated as "core". The face to face stakeholder meeting ratified inclusion of all outcomes from the Delphi and suggested that deterioration of the other leg and psychological morbidity should also be reported for both short and medium term studies., Conclusion: Consensus was established on 11 core outcomes for short and medium term studies. It is recommended that all future studies involving patients undergoing major lower limb amputation should report these outcomes., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to investigate outcomes for lower limb revascularisation for limb salvage within the National Health Service (NHS) in England., Methods: This was a retrospective observational study of administrative data. Data were extracted from the Hospital Episodes Statistics database for England. Data were included for a seven year period (1 April 2011-31 March 2018 inclusive) for all patients aged ≥ 18 years receiving surgery for peripheral arterial occlusive disease. Data were extracted for patient age, sex and frailty level, the NHS trusts undertaking the procedure, the technique used (angioplasty, bypass, endarterectomy, or hybrid), the mode of admission (elective or emergency), the surgical speciality, the financial year of admission, length of hospital stay during the procedure, subsequent emergency re-admission, revascularisation procedures within 30 days and subsequent amputation and mortality within one year and within five years. The primary outcome was one year amputation free survival. For analysis, data were separated into diabetic and non-diabetic patients. Multilevel modelling was used to adjust for hierarchy and observed confounding when investigating outcomes., Results: Data were available for 98 109 procedures across 124 hospital trusts. For non-diabetic patients (odds ratio 1.142, 95% confidence interval 1.068-1.222), one year amputation free survival was higher for angioplasty than for bypass. For diabetic patients, there was no difference in the primary outcome. One year amputation rates, 30 day emergency re-admission rates, and length of stay were all lower for angioplasty, and 30 day revascularisation rates were lower for bypass for both diabetic and non-diabetic patients., Conclusion: Outcomes were generally better for angioplasty than for bypass surgery for lower limb revascularisation for both diabetic and non-diabetic patients. The findings should be interpreted with caution given the likely different clinical presentations of those selected for each procedure. Future clinical trials may provide more definitive data., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this study is to investigate the impact of the coronavirus disease 2019 (COVID-19) lockdown period on the number and type of vascular procedures performed in the operating theater., Methods: A total of 38 patients who underwent 46 vascular procedures during the lockdown period of March 16th until April 30th, 2020, were included. The control groups consisted of 29 patients in 2019 and 54 patients in 2018 who underwent 36 and 66 vascular procedures, respectively, in the same time period. Data were analyzed using SPSS Statistics., Results: Our study shows that the lockdown during the COVID-19 pandemic resulted in a significant increase in the number of major amputations (42% in 2020 vs. 18% and 15% in 2019 and 2020, respectively; P-value 0.019). Furthermore, we observed a statistically significant difference in the degree of tissue loss as categorized by the Rutherford classification (P-value 0.007). During the lockdown period, patients presented with more extensive ischemic damage when than previous years. We observed no difference in vascular surgical care for patients with an aortic aneurysm., Conclusions: Measurements taken during the lockdown period have a significant effect on non-COVID-19 vascular patient care, which leads to an increased severe morbidity. In the future, policy makers should be aware of the impact of their measurements on vulnerable patient groups such as those with peripheral arterial occlusive disease. For these patients, medical care should be easily accessible and adequate., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Masked uncontrolled hypertension (MUCH), that is, nonhypertensive clinic but high out-of-office blood pressure (BP) in treated patients is at increased cardiovascular risk than controlled hypertension (CH), that is, nonhypertensive clinic and out-of-office BP. Using ambulatory BP, MUCH can be defined as daytime and/or nighttime and/or 24-hour BP above thresholds. It is unclear whether different definitions of MUCH have similar prognostic information. This study assessed the prognostic value of MUCH defined by different ambulatory BP criteria., Methods: Cardiovascular events were evaluated in 738 treated hypertensive patients with nonhypertensive clinic BP. Among them, participants were classified as having CH or daytime MUCH (BP ≥135/85 mm Hg) regardless of nighttime BP (group 1), nighttime MUCH (BP ≥120/70 mm Hg) regardless of daytime BP (group 2), 24-hour MUCH (BP ≥130/80 mm Hg) regardless of daytime or nighttime BP (group 3), daytime MUCH only (group 4), nighttime MUCH only (group 5), and daytime + nighttime MUCH (group 6)., Results: We detected 215 (29%), 357 (48.5%), 275 (37%), 42 (5.5%),184 (25%) and 173 (23.5%) patients with MUCH from group 1 to 6, respectively. During the follow-up (10 ± 5 years), 148 events occurred in patients with CH and MUCH. After adjustment for covariates, compared with patients with CH, the adjusted hazard ratio (95% confidence interval) for cardiovascular events was 2.01 (1.45-2.79), 1.53 (1.09-2.15), 1.69 (1.22-2.34), 1.52 (0.80-2.91), 1.15 (0.74-1.80), and 2.29 (1.53-3.42) from group 1 to 6, respectively., Conclusions: The prognostic impact of MUCH defined according to various ambulatory BP definitions may be different., (© The Author(s) 2020. Published by Oxford University Press on behalf of American Journal of Hypertension, Ltd.)

Purpose: To evaluate the midterm results of patients suffering from no-option chronic limb-threatening ischemia (CLTI) treated with a dedicated system for percutaneous deep venous arterialization (pDVA). Materials and Methods: Thirty-two consecutive CLTI patients (mean age 67±14 years; 20 men) treated with pDVA using the Limflow device at 4 centers between 11 July 2014 and 11 June 2018 were retrospectively analyzed. Of all patients, 21 (66%) had diabetes, 8 (25%) were on immunosuppression, 4 (16%) had dialysis-dependent renal failure, 9 (28%) had Rutherford category 6 ischemia, and 25 (78%) were deemed at high risk of amputation. The primary outcome was amputation-free survival (AFS) at 6 months. Secondary outcomes were wound healing, limb salvage, and survival at 6, 12, and 24 months. Results: Technical success was achieved in 31 patients (96.9%). The median follow-up was 34 months (range 16-63). At 6, 12, and 24 months, estimates were 83.9%, 71.0%, and 67.2% for AFS, 86.8%, 79.8% and 79.8% for limb salvage, and 36.6%, 68.2%, and 72.7% for complete wound healing, respectively. Median time to complete wound healing was 4.9 months (range 0.5-15). The DVA circuit occluded during follow-up in 21 patients; the median time to occlusion was 2.6 months. Reintervention for occlusion was performed in 17 patients: 16 because of unhealed wounds and 1 for a newly developed ulcer. Conclusion: This study represents the largest population of patients with no-option CLTI treated with pDVA using the LimFlow device with midterm results. In this complex group of patients, pDVA using the LimFlow device has been shown to be feasible, with a high technical success rate and AFS at 6 up to 24 months coupled with wound healing. In selected patients with no-option CLTI, pDVA could be a recommended treatment to prevent amputation and heal wounds.

Introduction: It is estimated that peripheral arterial disease occurs in one in five people aged over 60 years in the UK. Major lower limb amputation is a debilitating and life-changing potential outcome of peripheral arterial disease. A number of risk factors are involved in the development of the disease including smoking and diabetes. There is debate over the prevalence of major lower limb amputation in the UK with regional variations unexplained. The choice of data source can affect the epidemiological calculations and sources can also differ in the ability to explain variation. This study will aim to estimate the prevalence/incidence/number of major lower limb amputation in the UK. It will also identify sources of routinely collected electronic health data which report the epidemiology of major lower limb amputation in the UK., Methods and Analysis: A systematic search of peer-reviewed journals will be conducted in Medline, Excerpta Medica database, Cumulative Index of Nursing and Allied Health Literature, Allied and Complementary Medicine Database, The Cochrane Library and Scopus. A grey literature search for government and parliament publications, conference abstracts, theses and unpublished articles will be performed. Articles will be screened against the inclusion/exclusion criteria and data extracted using a pretested extraction form by two independent reviewers. Prevalence, incidence or number of cases (depending on data reported) will be extracted. Disagreements will be resolved by discussion. Data synthesis will be performed either as a narrative summary or by meta-analysis. Heterogeneity will be assessed using the I 2 statistic. If heterogeneity is low-moderate, pooled estimates will be calculated using random-effects models. If possible, meta-regression for time trends in the incidence of major lower limb amputation will be performed along with subgroup analysis, primarily in regional variation., Ethics and Dissemination: Ethics approval is not required for this study as study data are anonymised and available in the public domain. Dissemination will be by publication in a peer reviewed journal and by appropriate conference presentation. PROSPERO registration number CRD42020165592., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)