Pedal arch interrogation by ultrasound through systolic acceleration time measurement (Pedal Acceleration Time - PAT) is a recently described technique, that offers valuable insights into foot hemodynamics. Previous studies have demonstrated a correlation between PAT and the ankle-brachial index (ABI) and PAT has been proposed as a prognostic tool for wound healing in patients with peripheral artery disease (PAD). This study aims to assess the correlation between PAT and Transcutaneous Oxygen Pressures (TcPO2) in the diabetic foot population. 

Correlation between pedal acceleration time and transcutaneous oxygen pressures – a prognostic tool for wound healing in the diabetic foot population

BACKGROUND
Patients with diabetes and diffuse infrageniculate arterial disease who present with chronic limb-threatening ischemia require an exact anatomical plan for revascularization. Advanced pedal duplex can be used to define possible routes for revascularization. In addition, pedal acceleration time (PAT) can predict the success or failure of both medical and surgical interventions.


METHODS
A retrospective review of patients who were referred to our group for unilateral limb-threatening ischemia with isolated infrageniculate disease was conducted. Pedal duplex and PAT at the base of the wound was performed before and 1 week after intervention. The primary endpoint was limb salvage at 1 year. Revascularization was defined as direct or indirect based on the angiosome concept.


RESULTS
Fifty-four patients meeting inclusion criteria presented over a 5-year period (toe wound, n = 42; heel wound, n = 8; both, n = 4). At 1 year, 10 (18.5%) had required below-knee amputation, whereas the remainder had healed/improved. Limb salvage was predicted by absence of ongoing smoking, absence of dialysis, and postprocedural PAT (class I/II). Limb salvage did not correlate with direct versus indirect revascularization.


CONCLUSIONS
Advanced lower-extremity duplex in conjunction with determining PAT at the area of concern is a useful technique for mapping the vasculature and identifying targets for revascularization in patients with diffuse infrageniculate disease. Target artery revascularization to the wound bed resulting in a PAT less than 180 msec is predictive of limb salvage, regardless of whether perfusion is direct or indirect.

The Utility of Advanced Lower-Extremity Duplex Using Pedal Acceleration Time in the Management of the Threatened Diabetic Foot.

Introduction: The global burden of peripheral arterial disease and related critical limb ischemia has been increasing, and with it an increased incidence of limb loss and mortality. Multidisciplinary teams appear to have a beneficial impact on managing these complex patients, but measuring success depends on the outcome chosen. Determining the risk/benefit of intervention can be difficult, and there has been increasing emphasis on using frailty measures to predict the likelihood of morbidity and mortality after vascular interventions. Methods: We performed a retrospective review of patients referred to a multidisciplinary team over a 5-year period who underwent intervention. Data included the modified Frailty Index (mFI), Society for Vascular Surgery (SVS) WIfI wound score (0-2 vs 3), and pedal acceleration time (PAT) post-procedure. Outcomes analyzed were 1-year amputation-free survival (AFS-1), independence, and major complications. Results: There were 81 patients who underwent either open or endovascular revascularization. One-year amputation-free survival was positively correlated with post-procedure PAT (AFS-1 107.3 ± 25.5 vs non-AFS-1 174 ± 93; P = .025) and inversely related to wound score (SVS 3 AFS-1 5/17 [29%] vs SVS 0-2: 46/64 [72%]; P = .025). Independence was linked to wheelchair dependence prior to intervention with 6/16 (38%) patients patients spending more than 50% of their time in a wheelchair being independent versus 56/64 (88%) who were not wheelchair-dependent being independent (P = .005). An mFI ≥6 was associated with increased incidence of major complications at 1 year (mFI ≥6 11/31 [35%] vs mFI <6 5/50 [10%]; P = .018). Conclusion: One-year amputation-free survival was impacted by post-procedural success as measured by PAT, but negatively impacted by severity of wound at presentation. An mFI ≥6 was associated with greater incidence of complications. These findings may impact decision-making in determining the relative risk/benefit of revascularization in CLI. Vascular technologists can have an important role in development of limb salvage teams.

Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review

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Factors Predicting Outcome in Patients With Critical Limb Ischemia After Multidisciplinary Team Treatment: A 5-Year Single-Center Retrospective Review