Scientific Abstract Presentations: Reconstructive Session 2 Thursday, September 26 Thu, Sep 26 3:00-4:00 p.m. PDT

Introduction: In burn care, there is a noticeable lack of comprehensive studies on the incidence and risk factors related to Venous Thromboembolism (VTE) in burn patients. Understanding VTE in this context is crucial, as it can lead to severe complications and patient morbidity/mortality. This abstract investigates VTE incidence and risk factors in burn patients in hopes of informing VTE prevention measures and improving overall patient care in the field of burn medicine.

Methods: We conducted an analysis of the US National Trauma Data Bank (NTDB) spanning from 2007 to 2021 to identify burn-injured patients. Our primary focus was on determining the incidence of VTE. As predictor variables, we considered factors such as age, sex, smoking status, history of anticoagulation use, diabetes, and prior history of stroke. We abstracted comorbidities using event codes within the database.

Results: 442,623 patients were identified who had sustained burn injuries within the NTDB between 2007 to 2021. Among this cohort, 5,642 individuals (approximately 1.7%) experienced a VTE event during their hospitalization. Of these, 4,138 (79.6%) were deep vein thromboses and 1,504 (20.4%) were pulmonary emboli. Patients with VTE were significantly older than those without (37.7 versus 35.2, p<.001) and were significantly more likely to be male (82.5% vs. 78.9% p<.001) and obese (7.4% vs. 3.4% p<.001). Patients with VTE also had significantly higher %TBSA burns (16.5% vs. 13.2%, p<.001), were significantly more likely to be smokers (28.9% vs. 26.5%, p=.025), have preexisting hypertension (9.0% vs. 8.1%, p=.002), have a previous myocardial infarction (7.5% vs. 4.8%, p<.001), have alcohol use disorder (14.0% vs. 6.6%, p<.001) or have substance abuse (31.7% vs. 20.1%, p<.001). There were no signficant differences between the two cohorts in regard to history of stroke, peripheral vascular disease, diabetes mellitus, steroid use, or renal disease.

Conclusions: This study sheds light on several risk factors, including age, obesity, male sex, and comorbidities such as hypertension, myocardial infarction, and substance use disorders, which merit attention in clinical practice when selecting VTE prevention strategies. Addressing these factors and developing tailored interventions can help improve patient care, mitigate complications, and enhance outcomes. This study underscores the importance of considering VTE risk in burn patients as an integral component of comprehensive burn care.

Purpose: Somaliland is an autonomously run country in the Horn of Africa that is not internationally recognized. As such, it has been largely excluded by global health development programs, despite being the world's fourth poorest country (1). Accordingly, little work has been done to characterize the burden of this country's reconstructive surgical needs (2). The purpose of this study was to provide the first known description of the pattern and clinical profile of patients with cleft lip and palate (CLP) from this nation.

Methods: We performed a retrospective chart review on all patients who received CLP repair by a single surgeon on 40 separate surgical camps at Edna Adan University Hospital in Hargeisa, Somaliland between 2011-2024. Information regarding patient age, sex, cleft etiology, surgical management, and home location were retrieved. Home location coordinates were obtained using Google Maps. Extracted data was analyzed using Microsoft Excel.

Results: 767 patients (495 male, 64.5%) received 787 surgical procedures. Average age of primary surgery was 73.7-months. The most common etiology was left cleft lip with cleft palate (316, 41.2%). 2.4% of patients presented with isolated cleft palate. On average, males received treatment 17.1-m later than did females (79.7 and 62.6-m, respectively). Difference in treatment age was statistically significant (p=0.006). On subgroup analysis, patients who resided in the capital city of Hargeisa received their initial procedure an average of 17.8-m younger than those who lived outside of Hargeisa (62.9 and 80.7-m, respectively), which was found to be statistically significant (p=0.004).

Conclusions: In this severely economically depressed region, patients received treatment at ages that lagged far beyond recommended guidelines. Significantly lower than expected presentation of isolated cleft palate suggests that, given substantial financial limitations, families prioritized aesthetic over functional outcomes. Our finding of earlier treatment for females than males is rare in the literature and likely relates to cultural gender expectations (3)(4). Patients from rural locations were especially vulnerable to receiving delayed treatment. Given the disparities identified by this study, further efforts to decrease the burden of plastic surgery in Somaliland should be pursued in earnest.

1. Rosseau G, Kim EE, Barthélemy EJ, et al. The Current State of Neurosurgery in Somaliland. World Neurosurgery. 2021;153:44-51. doi:10.1016/j.wneu.2021.06.136
2. Concepcion T, Mohamed M, Dahir S, et al. Prevalence of Pediatric Surgical Conditions Across Somaliland. JAMA Network Open. 2019;2(1):e186857-e186857. doi:10.1001/jamanetworkopen.2018.6857
3. Paganini A, Hörfelt C, Mark H. Gender differences in surgical treatment of patients with cleft lip and palate. Journal of Plastic Surgery and Hand Surgery. 2018;52(2):106-110. doi:10.1080/2000656X.2017.1348951
4. Fell MJ, Hoyle T, Abebe ME, et al. The impact of a single surgical intervention for patients with a cleft lip living in rural Ethiopia. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2014;67(9):1194-1200. doi:10.1016/j.bjps.2014.05.019

-Background: Tissue flaps based on the superior epigastric artery and its perforators have been previously described by existing literature;(1-4) however, no specific study has been done on the perforators of the superior epigastric artery (SEA) with anatomical study, clinical application, and vessel imaging. The SEA perforator emerges just below the margin of the rib cage and supplies the skin in a transverse orientation to the midline, making it a strong choice for locoregional approaches to both chest and abdominal wall reconstructions. This flap also has the added benefit of reduced donor site morbidity, as it spares the fascia as well as the underlying rectus abdominis and lateral oblique muscles. In this study, we describe the SEA perforator flap through anatomical and clinical studies. -Methods: Aqueous contrast was injected into the internal thoracic arteries of 35 fresh cadavers. 114 SEA perforators were then dissected noting vessel caliber and vessel location on x-y axes. After achieving a reproducible and reliable technique, 5 patients underwent chest wall reconstruction and 1 underwent abdominal wall reconstruction all using flaps based on the SEA perforator. -Results: 62 perforators were dissected from right hemi-trunks, and 52 from left hemi-trunks. The mean arterial caliber of the perforators was 0.68 mm (SD = 0.31 mm), and they were located, on average, 2.66 cm in the x-direction and 4.9 cm in the y-direction, with the xiphoid process representing the midpoint (0,0). No significant differences in vessel caliber or location were found between the left and right sides. In our clinical cases, the mean dimensions of the donor flaps were 19.3 cm x 7.3 cm with a mean estimated area of 141.3 cm2. Donor sites were closed primarily and no major complications were noted. -Conclusion: Flaps based on the superior epigastric artery perforators are versatile, reliable, and reproducible, and thus, they represent a strong choice for chest and abdominal wall reconstructions.

References: 1. Uemura, T. (2007). Superior Epigastric Artery Perforator Flap: Preliminary Report. Plast Reconstr Surg, 120(1), 1-5. doi:10.1097/01.prs.0000263538.71343.b7 2. Maruyama, Y., Onishi, K., & Iwahira, Y. (1986). Reconstructing chest walls with vertical abdominal fasciocutaneous flaps. Scand J Plast Reconstr Surg, 20(79). 3. Tai, Y., & Hasegawa, H. (1974). A transverse abdominal flap for reconstruction after radical operations for recurrent breast cancer. Plast Reconstr Surg, 53(52). 4. Craggs, B., Stoel, A. M., Hendrickx, B., Zeltzer, A., & Hamdi, M. (2014). Superior Epigastric Artery Perforator Flap: Anatomy, Clinical Applications and Review of Literature. J Reconstr Microsurg, 30(7), 475-482. doi:10.1055/s-0034-1376399

Purpose: Patients generally report high rates of satisfaction following reduction mammaplasty, including the relief of premorbid physical and psychiatric symptoms, as well as enhanced body image and sexual function (1). Though surgical technique continues to evolve and improve, the loss of sensation remains an important concern in the postoperative period as sensation of the breast and nipple are paramount factors of women's psychological and sexual health (2). Sensation is only one of the multiple patient-specific factors that encompass post-operative patient satisfaction; thus, we sought to investigate the relationship between sensation with overall satisfaction to elucidate the importance of prioritizing sensation preservation when selecting a mammaplasty technique.

Methods: The OVID engine was used to search six databases including Scopus, Embase, and MEDLINE through October 2023 with predefined search terms and inclusion/exclusion criteria, in accordance with PRISMA methodology. Studies that reported both postoperative sensation outcomes and patient satisfaction in women who underwent reduction mammaplasties were included through screening by two independent reviewers.

Results: The review yielded 38 articles after exclusions, 32 of which were suitable for quantitative analysis. Studies were examined for the percentage of patients who reported no reduction in sensation of the breast and/or nipple-areolar complex postoperatively, as well as the percentage of patients who reported overall satisfaction with the procedure as excellent, good, acceptable, or fair. Across studies, mean overall satisfaction (M = 87.3%, SD = 13.5) was higher than mean sensation retention (M = 77.3%, SD = 22.7), (p = .029). A linear regression model demonstrated poor correlation between satisfaction and sensation (coefficient of regression = -0.072, 95% CI [-0.096,-0.050], R^2 = 0.011, p > 0.05). Analysis of studies by geographical region yielded no significant difference.

Conclusion: The results of this analysis suggest that overall patient satisfaction remains high irrespective of preservation or loss of sensation following breast reduction, a finding that provides valuable guidance for the shared decision making between patient and surgeon regarding mammaplasty technique selection. As novel advancements to breast surgeries emphasizing sensation preservation or restoration continue to emerge, more objective outcome tools and metrics to assess both sensation and satisfaction will be crucial in further characterizing this relationship.

References: 1.Lonie S, Sachs R, Shen A, Hunter-Smith DJ, Rozen WM, Seifman M. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. Gland Surg. 2019;8(4):431-440. 2.Lindau ST, Pinkerton EA, Abramsohn EM, et al. Importance of Breast Sensation After Mastectomy: Evidence from Three Sources. Womens Health Rep (New Rochelle). 2023;4(1):594-602. Published 2023 Dec 4.

Purpose: Previous studies have estimated the cost of free-flap performance on mission trips at $1,800-3,100 per patient (1)(2). There is a paucity of data on the cost of a free flap in rural Sub-Saharan Africa with staff that reside entirely in country. The purpose of this study was to investigate the cost of performing a free flap at such an institution.

Methods: We performed a retrospective audit of all resources expended on patients who received anterolateral thigh (ATL) flaps at a rural non-governmental institution in Kenya in 2023. Invoiced items from the operating room, surgical ward and the pharmacy were paired to local procurement costs. Staffing was calculated based on hourly wage. As the surgeon's stipend is entirely provided by a non-profit, it was not included in costs. Expenses that were inconsistently documented were calculated from averages of other known values.

Results: 11 patients (9 male) received ATL flaps. Average length of stay was 30.0 days. Average cost of free flap procedure was $548 ± 35, average cost of inpatient medications was $77 ± 57, average cost of hospital stay was $239 ± 177. Total cost associated with free flap performance was $864. There was no significant difference between patient age and procedure cost (p>0.05).

Conclusions: We present the first audit of ATL flap cost in rural Sub-Saharan Africa. Our findings suggest that, given availability of appropriate personnel, free flap procedures can be performed with greater cost-efficiency when performed by local teams. Free flap surgical mission trips should emphasize educational components.

1. Bouaoud J, Ndiaye MM, Benassarou M, Toure S, Schouman T, Bertolus C. Humanitarian Maxillofacial Mission's Success Requires Experienced Surgeons, Careful Planning, and Meeting With the Local's Care Needs. Journal of Oral and Maxillofacial Surgery. 2021;79(10):1999.e1-1999.e9. doi:10.1016/j.joms.2021.05.01
2. Huijing MA, Marck KW, Combes J, et al. Facial reconstruction in the developing world: a complicated matter. British Journal of Oral and Maxillofacial Surgery. 2011;49(4):292-296. doi:10.1016/j.bjoms.2009.08.044

Introduction Defects of the lower extremity often require free tissue transfer to provide adequate soft tissue reconstruction. However, flaps transferred to the lower extremity exhibit higher rates of complications when compared to other recipient sites, with failure rates of up to 10% reported.(1) The lower extremity poses additional challenges to the transferred tissue due to its dependent position, which subjects the tissue to significantly more venous pressure. Patients typically undergo a postoperative dangle protocol to condition the flap to mitigate the risk of venous congestion and resultant thrombosis. Dangle protocols vary widely in day of initiation and length of time.(2–4) The purpose of this study was to evaluate the safety and effects on length of stay of early initiation of a dangle protocol after traumatic lower extremity free flap reconstruction.

Methods A retrospective, cross-sectional, single institution review was conducted of all patients undergoing lower extremity free tissue transfer reconstruction from 2012-2022. Data analyzed included patient demographics, modality of injury, operative details, postoperative dangle protocol, complications, and length of stay. Patients were categorized into two different dangle protocols: Early dangle (starting within 5 days after surgery) and late dangle (starting at day 6 or greater after surgery). Univariate analysis was performed using student's t test; multivariate statistical analysis was performed using logistic regression and Cox regression, with significance determined to be p<0.05.

Results 99 patients underwent lower extremity free tissue transfer within the study period, and 83 patients met inclusion criteria. There were 22 patients in the early group and 61 patients in the late group. There were 17 fasciocutaneous flaps in the early group and 43 in the late group. There were 5 myocutaneous flaps in the early group and 18 in the late group. Free flap survival was 90.9% in the early group and 90.2% in the late group. The mean post-operative length of stay in the early and late groups were 12.3 and 18.8 days, respectively (p=0.0018). There was no difference in the number of patients who had wound healing complications, flap failure, or subsequent amputation in each group. The mean time to ambulation and mean hospital length of stay were similar between groups. The hazard ratio of delaying dangle initiation on time to discharge was 0.87 (p = 0.0017).

Conclusion The post-operative dangle protocol is a routine part of post-operative management for many patients after lower extremity free tissue transfer. Our results demonstrate that initiation of an early dangle protocol is safe and leads to a reduction in postoperative length of stay. This has significant cost implications and may help to reduce post-surgical complications such as deep vein thrombosis or hospital acquired infection. These results can be used to inform evidence-based recommendations for the optimal initiation and protocol for postoperative flap management in lower extremity reconstruction.

1. Soteropulos CE, Chen JT, Poore SO, Garland CB. Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review. J Reconstr Microsurg. 2019;35(1). doi:10.1055/s-0038-1667049
2. Rohde C, Howell BW, Buncke GM, et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg. 2009;25(1). doi:10.1055/s-0028-1090600
3. Jokuszies A, Neubert N, Herold C, Vogt PM. Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome. J Reconstr Microsurg. 2013;29(1). doi:10.1055/s-0032-1326736
4. Neubert N, Vogt PM, May M, et al. Does an Early and Aggressive Combined Wrapping and Dangling Procedure Affect the Clinical Outcome of Lower Extremity Free Flaps? - A Randomized Controlled Prospective Study Using Microdialysis Monitoring. J Reconstr Microsurg. 2016;32(4). doi:10.1055/s-0035-1568882

Introduction: While modern advancements in surgical techniques and prosthetic technology have improved outcomes and quality of life for amputees, issues such as heterotopic ossification (HO) remain a concern. (1-2) While various factors influencing HO development have been explored, the influence of gender and age remain insufficiently understood, despite their recognized impact on medical conditions. (3-4) Understanding gender-specific differences in HO formation is crucial for tailoring rehabilitation strategies and improving patient outcomes.

Methods: Chart review was conducted for transtibial amputees who sought care at one tertiary care center. HO presence was assessed on most recent X-ray, sociodemographic were collected through chart review, and propensity score matching was employed to balance covariates and create a homogeneous dataset for analysis. Multivariable linear regression analysis was performed to identify sociodemographic factors associated with HO formation post-amputation.

Results: A total of 655 limbs of 632 transtibial amputees (Male: 66.2%, median age: 52.2 (39.1-63.5)) were included. The average amputation-X-ray-interval was 1.7 years (0.3-6.2 years). Male gender OR=0.7, p=0.048) and younger age (OR=0.6, p=0.011) were independently associated with the HO presence. Moreover, symptomatic neuroma presence (OR=2.3, p<0.001) and passive nerve surgery (OR=2.1, p=0.010) remained independently associated with increased HO risk. Race, diabetes and obesity did not demonstrate significance (p>0.05).

Conclusion: - These findings underscore the importance of considering gender-specific factors in post-amputation care. - Recommendations for comprehensive patient care include implementing gender-specific rehabilitation protocols, preoperative screening for high-risk individuals and a multidisciplinary approach involving surgeons, endocrinologists, and pain management specialists. - Future research should focus on longitudinal studies with detailed hormonal and metabolic assessments.

Results 1. Potter BK, Burns TC, Lacap AP, Granville RR, Gajewski D. Heterotopic ossification in the residual limbs of traumatic and combat-related amputees. J Am Acad Orthop Surg. 2006;14(10 Spec No.). doi:10.5435/00124635-200600001-00042 2. Edwards DS, Clasper JC. Heterotopic ossification: a systematic review. J R Army Med Corps. 2015;161:315-321. doi:10.1136/jramc-2014-000277 3. Ranganathan K, Peterson J, Agarwal S, et al. Role of Gender in Burn-Induced Heterotopic Ossification and Mesenchymal Cell Osteogenic Differentiation. Plast Reconstr Surg. 2015;135(6):1631. doi:10.1097/PRS.0000000000001266 4. Bongetta D, Bua M, Bruno R, et al. Is Gender a Factor Affecting Long-Term Heterotopic Ossification Incidence After Single-Level Cervical Disc Arthroplasty? World Neurosurg. 2022;165:6-12. doi:10.1016/J.WNEU.2022.06.009

Abstract Background Abdominal wall reconstruction (AWR) is a treatment option for structural defects of the abdominal wall. (1) The most frequently cited publications related to AWR have not been quantitatively or qualitatively assessed. This bibliometric analysis characterises and assesses the most frequently cited AWR publications, to identify trends, gaps, and guide future efforts for the international research community. Methods The 100 most cited publications in AWR were identified on Web of Science, across all available journal years (from May 1964 to December 2023). Study details, including the citation count, main content focus, and outcome measures were extracted and tabulated from each publication. Oxford Centre for Evidence Based Medicine (OCEBM) Levels of Evidence (LOE) of each study were also assessed. (2) Results The 100 most cited publications in AWR were cited by a total of 9674 publications. Citations per publication ranged from 43 to 414 (mean 96.7 ± 52.48). Most publications were LOE 3 (n = 60), representative of the large number of retrospective cohort studies. The number of publications for LOE 5, 4, 3, 2 and 1 was 21, 2, 60, 2 and 12, respectively. The main content focus was surgical technique in 44 publications followed by outcomes in 38 publications. Patient reported outcome measures (PROMs) were used in 3 publications, and no publications reported validated aesthetic outcome measures. Conclusions Overall, 3 was the LOE for most frequently cited AWR publications, with more publications below LOE 3 than above LOE 3. Validated outcome measures and PROMs were infrequently incorporated in the studies evaluated.

References: 1) Boukovalas S, Sisk G, Selber JC. Abdominal wall Reconstruction: an Integrated approach. Seminars in Plastic Surgery. 2018;32(03):107-119. doi:10.1055/s-0038-1667062 2) Oxford Centre for Evidence-based medicine: Levels of Evidence (March 2009). Centre for Evidence-Based Medicine (CEBM), University of Oxford. October 1, 2020. Accessed: December 13, 2023. https://www.cebm.ox.ac.uk/resources/levels-of-evidence/oxford-centre-for-evidence-based-medicine-levels-of-evidence-march-2009.

Background: Patients with peripheral arterial disease (PAD) and comorbid major depressive disorder (MDD) have an increased risk of lower extremity amputation (LEA) compared to those without MDD [1]. A diagnosis of PAD is associated with concomitant MDD [2]. Targeted muscle reinnervation (TMR) has been shown to decrease postoperative pain with minimal change in complication rate or overall cost [3,4]. A psychiatric history of anxiety and/or depressive disorders has been shown to be predictive of opioid consumption after reconstructive surgery [5]. The aim of this study was to determine the risk of increased opioid consumption in PAD patients undergoing amputation, and the impact of TMR.

Methods: Data used in this study was collected from the TriNetX Network, which provided access to electronic medical records from approximately 114 million patients from 80 healthcare organizations. Patients with a history of PAD and LEA were included utilizing International Classification Code 10 and Current Procedural Terminology codes. These patients were divided into two cohorts based on TMR treatment following LEA. Propensity-score matching was performed to isolate the effect of TMR by balancing the effect of preoperative comorbid diagnoses between cohorts. Cohorts were assessed up to 1-year postoperatively for opioid use, antidepressant use, anxiety and depressive disorders, and all-cause mortality. Kaplan-Meier analysis was performed to assess events of reported opioid consumption and death, postoperatively. Continuous variables were compared using Student's t-test or Mann-Whitney U test. Categorical variables were analyzed using Pearson's χ2 or Fisher's exact test as appropriate. Comparative statistics were performed with a significance threshold set at an alpha value of 0.05, denoted as p<0.05.

Results: Of the 78,438 PAD patients, 78,310 underwent LEA alone while 128 underwent LEA with TMR. Before matching, TMR patients had greater preoperative diagnosis of anxiety (44.5% vs 16.3%, p<0.001) and/or depressive disorders (33.6% vs 18.9%, p<0.001) and invasive vascular interventions-including stent placement, balloon angioplasty, bypass graft, and other revascularization procedures (p<0.001). Risk analysis of matched cohorts up to 1-year after the index procedure showed no significant difference in all outcomes (p>0.05). This remained true when excluding patients with the measured outcome prior to surgery. Kaplan-Meier analysis showed that PAD patients undergoing LEA withTMR had a 26.9% lower risk of long-term opioid use compared to PAD patients undergoing LEA without TMR (HR: 0.731, 95% CI: 0.560-0.956, p=0.037).

Conclusion: There was no significant difference in postoperative psychiatric diagnosis, antidepressant use, and all-cause mortality among PAD patients undergoing LEA with and without TMR. Interestingly, when analyzing opioid use, the combination of a nonsignificant odds ratio and a significant hazards ratio indicates that while there might not be a difference in the odds of opioid use during our study window, there may be a significant difference in the rate of opioid use over the study duration.

References

1 Arya,S.et al.Theassociationofcomorbiddepressionwithmortalityandamputationin veteranswithperipheralarterydisease.JVascSurg68,536-545.e532(2018). https://doi.org:10.1016/j.jvs.2017.10.092 2 Brostow,D.P.,Petrik,M.L.,Starosta,A.J.&Waldo,S.W.Depressioninpatientswithperipheral arterialdisease:A systematic review.EurJCardiovascNurs16,181-193(2017). https://doi.org:10.1177/1474515116687222 3 Deeyor,S.T.,Kisana,H.M.,Hui,C.H.,Stecher,C. &Hustedt,J.W.TargetedMuscleReinnervationDoesNotIncreasetheRiskofPostsurgicalComplicationorOverallCost.Plast ReconstrSurgGlobOpen10,e4488 (2022). https://doi.org:10.1097/gox.0000000000004488 4 Reid,R. T.,Johnson,C. C.,Gaston,R. G.&Loeffler,B. J.ImpactofTimingofTargetedMuscle ReinnervationonPainandOpioidIntakeFollowingMajorLimbAmputation. Hand (N Y), 15589447221107696(2022). https://doi.org:10.1177/15589447221107696 5 Rodnoi,P.,Dickey,R.M.,Teotia,S.S.&Haddock,N.T.IncreasedOpioidConsumption followingDIEPFlapBreastReconstruction:EffectofDepressionandAnxiety. JReconstr Microsurg 38,742-748(2022). https://doi.org:10.1055/s-0042-1749595

Background: Multidisciplinary care with vascular and plastic surgery for a "vasculo-plastic approach" is critical to ensure the success of lower extremity (LE) free tissue transfer in the chronic wound population with diabetes and multi-level peripheral vascular disease (PVD). These patients require close surveillance to monitor their vascular status in order to maintain long-term limb salvage. While endovascular revascularization (ER) has been proven to be efficacious, the long-term success of this intervention has been shown to be variable (1). Restenosis is fairly common, reported to occur in up to 60% of patients within the first 12 months after percutaneous transluminal angioplasty (2-5). This study aims to identify the risk factors that precipitate a secondary endovascular intervention after LE FTT.

Methods: A retrospective analysis of all patients who underwent LE FTT between the years of July 2011 and January 2023 was performed. Patient demographics, comorbidities, pre-FTT lab values, pre-FTT angiogram details, intraoperative details, post-FTT complications, post-FTT angiograms, post-FTT endovascular interventions, and long-term outcomes were collected. Patients who underwent a post-FTT vascular procedures were compared to those who did not receive post-FTT vascular procedures. Univariate and multivariate analysis were performed on patients with who received post-FTT endovascular revascularization.

Results: Among 300 patients who underwent LE FTT, 18.3% (n=55) patients received ER of at least one LE vessel prior to their FTT. Following FTT, 10% (n=30) were indicated for post-FTT ER, which was performed at a median of 161.5 (IQR:373) days after FTT. Patients who underwent ER post-FTT) had a higher median Charlson Comorbidity Indices (CCI) (5 vs. 4, p=0.000), rates of diabetes mellitus (DM) (96.7% vs. 49.8%, p=0.000), and chronic kidney disease (CKD) (36.7% vs. 13.0%, p=0.001), compared to patients who did not undergo ER post-FTT. The rates of amputation between those who received a post-FTT ER vs. patients who did not were similar (13.3% vs. 12.6%, p=1.000). Univariate analyses were performed for all possible confounding covariates. On multivariate logistic regression, covariates that remained independent for a higher risk of post-FTT ER included DM (OR:15.2, CI:1.3-182.2), forefoot defects (OR:5.5, CI:11.2-24.5), pre-FTT intervention (OR: 24.5, CI:5.3-112.7), chronic osteomyelitis (OR:5.9, CI:1.4-25.4), and intraoperative thrombosis (OR:164.4, CI:4.3-6303.3).

Conclusion: 10 percent of the free flap patient population required post-FTT vascular intervention to ensure long-term limb salvage. Patients who receive pre-FTT endovascular revascularization are 24.5 times more likely to receive additional endovascular interventions to maintain a healthy vascular status after their LE FTT. This further emphasizes the need for an intensive multidisciplinary vasculo-plastic approach in these patients, with intensive follow-up and low threshold for re-intervention.

Citations: 1. Borozan PG, Schuler JJ, Spigos DG, Flanigan DP. Long-term hemodynamic evaluation of lower extremity percutaneous transluminal angioplasty. J Vasc Surg. 1985 Nov;2(6):785-93. PMID: 2932561. 2. Schillinger M, Minar E. Restenosis after percutaneous angioplasty: the role of vascular inflammation. Vasc Health Risk Manag. 2005;1(1):73-8. doi: 10.2147/vhrm.1.1.73.58932. PMID: 17319099; PMCID: PMC1993932. 3. Gallino A, Mahler F, Probst P, et al. Percutaneous transluminal angioplasty of the arteries of the lower limbs: a 5 year follow-up. Circulation. 1984;70:619–23. 4. Schillinger M, Exner M, Mlekusch W, et al. Vascular inflammation and percutaneous transluminal of the femoropopliteal artery: association with restenosis. Radiology. 2002a;225:21–6. 5. Varela D.L., Armstrong E.J. Endovascular Management of Femoropopliteal In-Stent Restenosis: A Systematic Review. Cardiovasc. Revasc. Med. 2019;20:915–925. doi: 10.1016/j.carrev.2018.10.028.