Kara A Rothenberg1, Elizabeth L George2, Amber W Trickey3, Venita Chandra4, Jordan R Stern5. 1. Department of Surgery, University of California San Francisco - East Bay, Oakland, CA; Division of Vascular Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA. Electronic address: krothenb@stanford.edu. 2. Division of Vascular Surgery, Stanford University, Stanford, CA; Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA. 3. Stanford-Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, CA. 4. Division of Vascular Surgery, Stanford University, Stanford, CA. 5. Division of Vascular Surgery, Stanford University, Stanford, CA; Division of Vascular Surgery, Palo Alto VA Health System, Palo Alto, CA.
Abstract
BACKGROUND: Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes. METHODS: Patients who underwent lower extremity revascularization for ALI from 2005 to 2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations among patient characteristics, comorbidities, fasciotomy timing, and patient outcomes were evaluated. RESULTS: A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford ALI classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, P < 0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, P = 0.003). Ischemia time >6 hr was noted in 66.7% of patients, although this was not significantly associated with fasciotomy occurrence (≤6 hr 21.7% fasciotomy vs. >6 hr 34.8% fasciotomy, P = 0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, P = 0.002). CONCLUSIONS: The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.
BACKGROUND: Compartment syndrome (CS) is a feared complication after revascularization for acute limb ischemia (ALI), and patients often undergo prophylactic 4-compartment fasciotomy at the time of revascularization to avoid developing CS and its associated complications. However, fasciotomy carries its own morbidity and surgeons may opt against this initially. The subsequent development of CS would mandate fasciotomy in a delayed fashion. We sought to investigate relationships between fasciotomy timing and patient outcomes. METHODS:Patients who underwent lower extremity revascularization for ALI from 2005 to 2017 were retrospectively identified from an institutional database. Fasciotomy was classified as either prophylactic (occurring with revascularization) or delayed. Associations among patient characteristics, comorbidities, fasciotomy timing, and patient outcomes were evaluated. RESULTS: A total of 138 patients met study inclusion criteria. Forty-two patients (30.4%) underwent fasciotomy, and of these, 8 (19%) were delayed. Patients with higher Rutherford ALI classification were more likely to undergo fasciotomy (I 4.2%, IIA 13.2%, IIB 53.3%, P < 0.001), and patients with coronary artery disease were less likely (16.1% vs. 83.9% fasciotomy, P = 0.003). Ischemia time >6 hr was noted in 66.7% of patients, although this was not significantly associated with fasciotomy occurrence (≤6 hr 21.7% fasciotomy vs. >6 hr 34.8% fasciotomy, P = 0.17). Patients undergoing delayed fasciotomy were more likely to require major amputation within 30 days (50% vs. 5.9%, P = 0.002). CONCLUSIONS: The decision to perform prophylactic fasciotomy in the setting of ALI is complex. When not performed, the subsequent development of CS requiring delayed fasciotomy appears to be associated with increased risk of major amputation at 30 days. This suggests that a liberal approach to prophylactic fasciotomy at the time of revascularization may improve limb salvage rates.
Authors: Nelson Merchan; Bailey Ingalls; Jayden Garcia; John Wixted; Tamara D Rozental; Carl M Harper; Arriyan S Dowlatshahi Journal: J Am Acad Orthop Surg Glob Res Rev Date: 2022-02-21