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

• Fontaine stage IV peripheral arterial disease (PAD) of the foot and distal lower leg
• If peripheral vascular reconstruction is not possible, transtibial amputation must have been ruled out and more distal amputation options exhausted
• Ideally, the deep femoral artery (DFA) should be patent, as otherwise healing of the femoral stump is at risk; possibly, reconstruction of the DFA should be attempted first

Classification of PAD according to Fontaine stage and Rutherford category

• General inoperability
• Amputation can be performed more distad
• Necrosis up to about one handbreadth inferior to the knee
• Massive infection of the lymphatic vessels in the lower leg

DSA

• Preoperative DSA mandatory to demonstrate local inoperability regarding revascularization
• No major amputation without angiography in PAD cases
• Possibly, transcutaneous pO2 measurement to determine the amputation level

Laboratory panels

• Complete blood count
• Electrolytes
• Kidney function parameters
• Coagulation
• Blood group

Resting ECG

Chest X-ray

• Perioperative antibiotic prophylaxis
• Ready 2 packed red blood cells

• Allergy/intolerance, e.g., to latex, drugs; acute cardiovascular response; intensive care measures; possibly permanent damage (e.g., organ failure, brain damage, paralysis)
• Secondary bleeding, hematoma, possibly reoperation
• Transfusion of allogeneic blood / blood components: risk of contracting hepatitis, HIV
• Skin, tissue and nerve damage due to positioning, measures accompanying the procedure (injections, disinfection, current); possibly long-term sequelae (pain, paralysis, inflammation, necrosis)
• Impaired wound healing, infection, osteitis, fistula formation; possibly reoperation, reamputation, sepsis
• Thrombosis/embolism
• Keloids, neuroma, phantom (limb) pain
• Functional impairment of the rstump, contralateral limb or spine due to incorrect weight bearing