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Predisposing factors for amputation of lower extremities in diabetic patients with foot ulceration in the state of Sergipe (Portuguese PDF version) Marco A ntonio Prado Nunes, 1 Karla Freire Resende, 2 A ldemar A raújo Castro, 3 Guilherme Benjamin Brandão Pitta, 4 Luis Francisco Poli de Figueiredo, 5 Fausto Miranda Jr. 6 1. Assistant profe ssor, Biostatistics, Unive rsidade Tirade nte s, Aracaju, SE, Brazil. 2. Assistant profe ssor, De partm e nt of Me dicine , Unive rsidade Fe de ral de Se rgipe , Aracaju, SE, Brazil. 3. Assistant profe ssor, De partm e nt of Social Me dicine , Fundação Unive rsitária de C iê ncias da Saúde de Alagoas, Escola de C iê ncias Mé dicas de Alagoas, Mace ió, AL, Brazil. 4. Associate profe ssor, De partm e nt of Surgical C linic, Fundação Unive rsitária de C iê ncias da Saúde de Alagoas, Escola de C iê ncias Mé dicas de Alagoas, Mace ió, AL, Brazil. 5. Profe ssor, Surgical Te chnique and Ex pe rim e ntal Surge ry, De partm e nt of Surge ry, Unive rsidade Fe de ral de São Paulo (UNIFESP), São Paulo, SP, Brazil. 6. C oordinator of Graduation and He ad of Vascular Surge ry, Unive rsidade Fe de ral de São Paulo - Escola Paulista de Me dicina (UNIFESP-EPM), São Paulo, SP, Brazil. Correspondence: Marco Antonio Prado Nune s Av. Anízio Aze ve do, 351/502, Bairro 13 de Julho C EP 49020-240 - Aracaju, SE - Brazil Te l: +55 (79) 3246.2918; +55 (79) 9988.2862 E-m ail: m [email protected] .br

A BSTRA CT Objective: To de te rm ine the pre disposing factors for am putation of lowe r lim bs in diabe tic patie nts with foot ulce ration. Methods: The re se arch was carrie d out in hospitals, and all diabe tic patie nts with foot ulce ration we re include d. Am putation was studie d in re lation to age , se x , pre vious am putation, num be r of ulce rs, tim e of diagnosis of diabe te s m e llitus, tim e of ulce ration, ave rage num be r of days in hospital, W agne r's classification, and pre se nce of foot pulse . Result: W e ve rifie d that 55% (44/80) of the patie nts progre sse d to som e type of am putation of the lowe r lim bs; m e an age was 61 ye ars, but the occurre nce of am putation was significantly highe r in the age group be twe e n 60 and 90 ye ars (P = 0.03). W e did not obse rve a significant variation in the following variable s: tim e of diagnosis of diabe te s, tim e of ulce ration, and hospitalization tim e in re lation to the group of patie nts who we re am putate d. Ne ve rthe le ss, the m ost se ve re le sions, whe n e valuate d by W agne r's classification (P < 0.001) and by the abse nce of both distal pulse s (P < 0.001) of lowe r lim bs, turne d out to be ve ry significant in re lation to the am putation outcom e . Conclusion: The se ve rity of le sions, the abse nce of pulse and age ove r 60 ye ars we re conside re d pre disposing factors for am putation in the se patie nts. Key words: Am putation, diabe te s m e llitus, diabe tic foot, ulce r. J Vasc Bras. 2006;5(2):123-30 Article subm itte d Nove m be r 22, 2005, acce pte d June 7, 2006.

INTRODUCTION The am putation of lowe r lim bs is one of the m ain conse que nce s of diabe te s m e llitus and foot ulce ration. 1 The risk of diabe tic patie nts be ing subm itte d to lowe r lim b am putations is 15 tim e s highe r than non-diabe tic patie nts; 1.7% of all hospitalizations re late d to the diabe te s m ay be attribute d to this proce dure , 2 and approx im ate ly 10% of the costs with he alth care of diabe tic patie nts are associate d with am putations. 3 O ve r the past ye ars, the diabe tic foot has be e n discusse d by se ve ral organizations and institutions worldwide , with spe cial atte ntion to change s in the approach and tre atm e nt, in orde r to achie ve a re duction of 50% in the num be r of am putations, a goal that has be e n se t at the Saint Vince nt De claration about diabe tic care in Europe . This de claration e stablishe s obje ctive s to control the dise ase , re ducing its m ain com plications (the diabe tic foot is one of the m ), and aim s at e lim inating the im pact of the dise ase by prom oting he alth, pre ve ntive m e dicine and be tte r-quality care . 4,5

http://www.jvascbr.com.br/06-05-02/06-05-02-123/06-05-02-123.htm

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Jornal Vascular Brasileiro The re fore , to achie ve the goals of re ducing the num be r of am putations, it is ne ce ssary to k now the patie nts' ne e ds in de tail and the way the y are be ing tre ate d, to de fine what and how m uch ne e ds to be done to im prove the e volution of such patie nts. A m ajor conce rn is that the re is no vascular surge ry se rvice available to tre at and pe rform proce dure s, such as arte rial re vascularization of lowe r lim bs, for patie nts supporte d by the Unifie d He alth Syste m (UHS) in the state of Se rgipe , Brazil, so the y are be ing subm itte d to prim ary am putation. This study thus aim s at de te rm ining the pre disposing factors for the am putation of lowe r lim bs in a group of diabe tic patie nts with foot ulce ration in hospitals be longing to the UHS ne twork , as we ll as at ve rifying the use of spe cific the rape utic te chnique s for the care of vascular le sions in the se patie nts.

METHODS All patie nts with foot ulce ration and diabe te s m e llitus or that had this diagnosis during hospitalization in ge ne ral hospitals that provide te rtiary care to UHS m e m be rs and are pre pare d for the tre atm e nt of patie nts with vascular dise ase s in the state of Se rgipe we re followe d-up from July to De ce m be r 2004. Patie nts who die d during hospitalization, pre gnant wom e n and those who pre se nte d re striction of fre e dom or of the e x planation ne ce ssary to obtain the prope r conse nt we re e x clude d. The re se arch was carrie d out according to the re solution 196/96 of the Brazilian He alth C ouncil and to the He lsink i De claration and was approve d by the R e se arch Ethics C om m itte e of the Unive rsidade Estadual de C iê ncias da Saúde de Alagoas, protocol 236 of 2004. A non-probabilistic, conve nie nce sam ple was use d. O ve r a 6-m onth pe riod, the re se arche rs m ade a daily active se arch of patie nts with diabe tic foot in the thre e hospitals and, afte r the ir conse nt, pe rform e d clinical e x am inations, with anam ne sis and physical e x am ination. Ne x t, the patie nts we re followe d-up during all the hospitalization tim e , whe n the clinical e volution and the m e dical charts we re obse rve d, with the pe rm ission of the hospital adm inistrators. All re le vant data we re re corde d in a standardize d form . The prim ary variable of the re se arch was the pe rform ance of proce dure s of lowe r lim b am putations during hospitalization. The variable s analyze d in re lation to the prim ary variable we re : age , se x , pre vious am putation, num be r of ulce rs, tim e of diagnosis of diabe te s, tim e of ulce ration, ave rage num be r of days in hospital, W agne r's classification, pre se nce of foot pulse , and the pe rform ance of spe cialize d vascular surgical and/or inte rve ntional proce dure s in this group of patie nts. The am putation le ve l - m ajor or m inor - for e ach patie nt was also re corde d. The re was no diffe re ntiation be twe e n the type s of diabe tic foot, i.e ., whe the r it was ische m ic, ne uropathic, infe ctious or com bine d, since the y we re all ulce rate d fe e t and, in ge ne ral, in an advance d stage . The diabe tic foot was de fine d as a condition of infe ction, ulce ration and/or de struction of the de e p tissue s associate d with ne urological abnorm alitie s and se ve ral le ve ls of pe riphe ral vascular dise ase in lowe r lim bs. 6 The diabe te s m e llitus was diagnose d whe n the fasting glucose was highe r or e qual than 126 m g/dl in two m e asure m e nts. 7 The am putation was de fine d as a transve rsal re se ction of the te rm inal part of the lim b, be ing conside re d m ajor whe n pe rform e d above the ank le joint and m inor whe n pe rform e d be low it. 6,8 W ith the aim of studying the re lations be twe e n the variable s m e ntione d above and the outcom e of the lowe r lim b am putation in patie nts with diabe tic foot, the Stude nt's t te st was use d for continuous variable s to com pare the ave rage s be twe e n am putate d and non-am putate d patie nts. W ith re gard to discre te variable s, the chi-square te st was use d to e valuate the inde pe nde nce be twe e n the se variable s and the am putation variable . Binom ial proportions se t the confide nce inte rvals for e ach variable analyze d, and the n a logistic re gre ssion analysis was applie d to the data, in orde r to pre dict the probability of the re sponse variable , due to the e x planatory variable s, according to the m ode l. The statistical te sts we re pe rform e d with a 5% probability le ve l. RESULTS O ve r a 6-m onth pe riod, 92 diabe tic patie nts we re hospitalize d with foot ulce ration in the thre e hospitals that provide this type of care for UHS patie nts in the state of Se rgipe , Brazil. During the obse rvation pe riod, 12 patie nts die d, avoiding the analysis of the ir final outcom e and we re , the re fore , e x clude d from the study. W ith re gard to the othe r 80 patie nts, we ve rifie d that 55% (44/80) progre sse d to som e type of lowe r lim b am putation; 59% (47/80) of the patie nts we re fe m ale , 41% (33/80) we re m ale , and m e an age was 61 ye ars (Table 1), ranging from 37 to 98 ye ars. The re port of pre vious am putation was ve rifie d in 22% (18/80) of patie nts; of the se , 72% (13/18) we re subm itte d to a ne w proce dure . As to the num be r of ulce rs, 63% (47/74) of the patie nts pre se nte d only one foot ulce r and 36% (27/74) had two or m ore ulce rs. Table 1 - A ge, time of diagnosis of diabetes, time of ulceration and number of days in hospital in patients with diabetic foot* Variables

Mean Median Mode

Standard deviation

95% confidence intervals 59-65

Age

62

61

63

11.58

TDD

10

10

10

8.64

8-12

TU

75

30

60

123.57

46-104

DH

16

15

16

11.92

13-19

DH = number of days in hospital; TDD = time of diagnosis of diabetes, in years; TU = time of ulceration, in days. * Number of valid observations.

The chi-square te st did not find any significance for the variable s se x (P = 0.94), num be r of ulce rs (P = 0.08) and pre vious am putation (P = 0.11). The re fore , the hypothe sis of inde pe nde nce be twe e n e ach variable and the outcom e of lowe r lim b am putation was acce pte d (Table 2). Table 2 - Sex, age group, Wagner's classification, number of ulcers, previous amputation and presence of pulse in patients with and without lower limb amputation

DF C hi-square

Sex

AG

WC

NU

PA

1

1

1

1

1

2

0.00

4.70

21.49

3.03

2.58

17.80


PP

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0.94

0.03*

0.00†

0.08

0.11

0.00†

AG = age group; DF = degrees of freedom; NU = number of ulcers; PA = previous amputation; PP = presence of pulse; WC = Wagner's classification. * Significant at a 5% level of probability. † Significant at a 1% level of probability. R e garding the tim e of diagnosis of diabe te s, m e an was 10 ye ars, ranging from 0 to 40 ye ars (Table 1). The tim e of ulce ration m e asure d in days (Table 1) showe d a ve ry high variation coe fficie nt, but the m e an indicate s that half of the patie nts had ulce rs for le ss than 30 days, whe re as the othe r half had a highe r tim e of ulce ration. The m e an hospitalization tim e of the total group and of those subm itte d to am putation was 16 days. W he n the outcom e of am putation was analyze d in re lation to the m e an age s, tim e of diagnosis of diabe te s, tim e of ulce ration and num be r of days in hospital, we ve rifie d that the re we re no significant diffe re nce s be twe e n the m , according to the t te st at a 5% significance le ve l (Table 3), although we ve rifie d that the occurre nce of am putation was significantly m ore fre que nt in the age group from 60-90 ye ars, whe n com pare d to the age group from 40-60 ye ars (P < 0.05). Table 3 - A ge, time of diagnosis of diabetes, time of ulceration and number of days in hospital in patients with and without lower limb amputation A mputation

Mean of variables A ge

TDD

TU

DH

No

60

11

85

16

Ye s

64

9

67

16

t value

1.81

0.80*

1.02*

0.64*

P

0.07

0.42

0.31

0.52

DH = number of days in hospital; TDD = time of diagnosis of diabetes, in years; TU = time of ulceration, in days. * The results are based on the transformed data.

W ith re gard to the analysis according to W agne r's classification, 9 we ve rifie d that 35% (28/80) of the patie nts pre se nte d grade III ulce rs or lowe r and 61% (49/80) pre se nte d grade s IV and V; of the 45% (36/80) classifie d as grade IV, 69% (25/36) we re am putate d, 60% (15/25) of m inor am putations and 40% (10/25) of m ajor am putations; of the 16% (13/80) conside re d grade V, 92% (12/13) we re subm itte d to the proce dure , m ost of the m , i.e ., 92% (11/12) to m ajor am putations. As to the pre se nce of distal pulse s, which corre sponde d to the dorsalis pe dis and poste rior tibial arte ry, 20% (16/80) pre se nte d only one of the m , and 44% (35/80) did not pre se nt any palpable pulse . Ne ve rthe le ss, in 36% (29/80) both pulse s of the affe cte d lim b we re palpate d. W he n analyzing the se data in re lation to the outcom e of am putation, we ve rifie d that 80% (28/35) of the patie nts who did not have any of the ir pulse s palpable we re subm itte d to the proce dure ; of the se , 71% (20/28) we re m ajor am putations and 29% (8/28) we re m inor. O n the othe r hand, am ong those who pre se nte d both pulse s, only 27% (8/29) we re am putate d, 75% (6/8) we re m inor am putations and 25% (2/8) we re m ajor. De spite all that, only 5% (4/80) of the patie nts we re subm itte d to re vascularization of lowe r lim bs with graft inte rposition. The hypothe sis of inde pe nde nce be twe e n the variable s of W agne r's classification and am putation and be twe e n pre se nce of pulse and am putation was re je cte d by the chi-square te st at a 5% le ve l, also lowe r to the 1% le ve l of probability (Table 2). Ne x t, the se data we re applie d in the logistic re gre ssion analysis, with the aim to e valuate the probability of the de pe nde nt variable am putation. The ste pwise m e thod was use d, se le cting the variable s W agne r's classification and pre se nce of pulse , which e nte re d the m ode l base d on the ir e ffe ct on the inde pe nde nt variable , at a 0.05 significance le ve l (Table 4). Table 4 - Parameters selected for the model with the degrees of freedom and estimates of regression coefficients, standard errors, and chi-square tests Parameters

DF

Estimates

Standard error

Chi-square

P

Inte rce pt

1

-2.2159

0.9995

4.9155

0.026*

WC

1

0.9770

0.2591

14.2239

0.000†

PP

1

-0.8234

0.3460

5.6626

0.017*

DF = degrees of freedom; PP = presence of pulse; WC = Wagner's classification. * Significant at a 5% level of probability. † Significant at a 1% level of probability.

The analysis of origin or place of re side nce showe d that 20% (16/80) live d in the city of Aracaju, 71% (57/80) cam e from the countryside or rural are as in the state of Se rgipe , and 9% (7/80) live d in othe r state s: one in Pe rnam buco, two in Alagoas, and five in Bahia. DISCUSSION Since the re is a m ajor conce rn with the re duction of the high am putation rate s in diabe tic patie nts and due to the com ple x ity of the conditions that influe nce such outcom e , m ore studie s are ne ce ssary to guide the use of diffe re nt pre ve ntive and the rape utic strate gie s. 10 The re fore , an obse rvational prospe ctive study was carrie d out to analyze the progre ss of patie nts with diabe te s m e llitus, aim ing to im ple m e nt pre ve ntion and tre atm e nt strate gie s for the se patie nts and, conse que ntly, try to re duce the incide nce of proce dure s that could be partly avoide d. Ne ve rthe le ss, it should be conside re d that the sam ple of the population is com pose d of patie nts who we re hospitalize d due to m ore se ve re le sions and clinical status than whe n com pare d with those who would re ce ive outpatie nt care ; the re fore , the re m ight have be e n a se le ction bias.


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Jornal Vascular Brasileiro The se le ction of patie nts was m ade in the hospital be cause the spe cialize d outpatie nt and hospital se rvice s for the tre atm e nt of UHS patie nts had no structure , le ading the se patie nts to se e k e m e rge ncy se rvice s, whe re the y we re hospitalize d and e valuate d by ge ne ral surge ons, who conducte d the tre atm e nt. The re was no vascular surge ry se rvice available to tre at and pe rform proce dure s, such as arte rial re vascularization of lowe r lim bs, for the se patie nts in the state of Se rgipe . Aracaju was the city to which all patie nts in the state we nt to pe rform m e dium - and high-com ple x ity proce dure s. O ve r a 6-m onth pe riod, the hospitalizations of 80 diabe tic patie nts with chronic foot ulce rs we re followe d up. W e obse rve d that 55% (44/80) of the patie nts de ve lope d som e type of am putation. Although it has be e n de m onstrate d that the re are significant diffe re nce s in the global incide nce of am putations in diabe tic patie nts, 11 it is a high num be r in re lation to som e inte rnational studie s, which showe d that 11 to 29% of the diabe tic patie nts who have foot ulce rs are am putate d. 12-15 It is also surprising that only 5% (4/80) of the patie nts we re subm itte d to any type of re vascularization surge ry of lowe r lim bs. The se data, whe n confronte d with re ports inform ing that re vascularization proce dure s, surgical or e ndovascular, we re m ade in 25% of the patie nts with diabe tic foot, 9 sugge st that the pe riphe ral vascular the rape utic te chnique s are be ing unde ruse d for the care of the patie nts e valuate d in this study. C onside ring the im portance of the spe cialize d care in vascular surge ry to save the lim b of this type of patie nt, the y obse rve d that the num be r of patie nts subm itte d to m ajor am putations of lowe r lim bs was re duce d in 75% and sugge ste d that the num be rs we re re late d to the se ve n-fold incre ase in the use of arte rial re construction. 16 In anothe r study, the annual num be r of am putations due to vascular dise ase s was also e valuate d, showing that it was re duce d in 28%, at the sam e tim e in which the fre que ncy of infrainguinal vascular re pair surge rie s alm ost quadruple d. 17 The se studie s sugge st that the vascular surge ry m ay be re sponsible for the significant re duction in am putation rate s, which is one of the m ain obje ctive s of re constructive arte rial surge ry - the pre se rvation of the lim bs that suffe r from critical ische m ia. The re lation be twe e n incide nce of am putations and the se ve rity of le sions was e valuate d using the classification propose d by W agne r, 18 showing that the m ost se ve re and de e pe r le sions we re the m ost fre que nt and also the one s that m ore fre que ntly le d to am putation, which sugge sts that the se ve rity of le sions m ay be conside re d a significant factor to de te rm ine the possibility of am putation. W agne r's classification was chose n for be ing sim ple and e asy to use , e ve n by ge ne ral practitione rs. Howe ve r, it is base d on the ulce r de pth and doe s not conside r the infe ction and the pe riphe ral occlusive arte rial dise ase , which have an additional e ffe ct on the de pth with re gard to the se ve rity of le sions. 15 The num be r of ulce rs did not prove to be a significant factor to de te rm ine the am putation in the pre se nt study. Arm strong e t al. 15 obse rve d a te nde ncy to incre ase the pre vale nce of am putation whe n the wound was progre ssive ly de e pe r, and the patie nts we re 11 tim e s m ore lik e ly to have a foot or m ajor am putation if the wound re ache d the bone . The ulce r are a, although it has not be e n e valuate d, also se e m s to be associate d with a highe r possibility of am putation. 19 Most patie nts pre se nte d change s in the distal pulse s. In 44% (35/80), any distal pulse was palpate d; of the se , 80% (28/35) we re subm itte d to am putation of one of the lowe r lim bs. The re fore , the data from this study show that the patie nts who did not pre se nt distal pulse s, in case the y are not re vascularize d, progre ss to am putation. The arte rial dise ase m ay be conside re d one of the m ain risk factors for foot ulce rs. 20-22 It also contribute s to a highe r possibility of lowe r lim b am putations. 15-23 The palpation te chnique of distal pulse s was use d, since it is re com m e nde d as an e fficie nt scre e ning instrum e nt for the arte rial occlusive dise ase . 22 The m e an age of the individuals who we re am putate d doe s not diffe r m uch from the group of patie nts with foot ulce rs (64 and 62 ye ars, re spe ctive ly), be ing a little younge r in re lation to othe r countrie s. 24-26 Ne ve rthe le ss, whe n the y are analyze d in re lation to age group, the re is an incre ase in the incide nce of am putations as the age incre ase s, be ing conside re d significantly m ore fre que nt in the group age d 60 ye ars or m ore . The re fore , the re is a te nde ncy of am putation in olde r patie nts, a fact that has be e n obse rve d in othe r studie s. 13-25 Larsson e t al. re port that the m ale patie nts are subm itte d to the proce dure at a younge r age than fe m ale patie nts, 24 but it did not occur in this study. As to the num be r of days in the hospital, the re was a m e an num be r of 16 days for patie nts with diabe tic foot, with m e dian of 15 days. The se data are com parable to those in the state of C alifornia, which in its turn pre se nts a hospitalization tim e significantly shorte r than the Ne the rlands (41 days) and Spain (51 days). 25,27 The two latte r ce nte rs have curiously re porte d a lowe r fre que ncy of am putations in re lation to C alifornia and to this study, sugge sting that, to save the lim b, the re m ight be the ne e d of care s that de m and m ore num be r of days in the hospital for som e patie nts. This is im portant, since le ss days in the hospital re fle ct an appare nt lowe r dire ct financial cost for the hospital providing care to the patie nt; howe ve r, the am putation le ads to a highe r social, hum an and financial cost for the he alth syste m , the socie ty and the patie nts the m se lve s. 28 The tim e of ulce ration was also e valuate d. The re was a gre at variation in the data colle cte d in this study, although the m e dians of tim e of ulce ration in patie nts with diabe tic foot and am putate d patie nts, from the date the le sions we re discove re d until hospitalization, are ve ry sim ilar - 37 and 30 days, re spe ctive ly. Sim ilarly to this study, the authors re porte d a gre at variation in the tim e of ulce ration in a study from England, re lating it to the patie nt's difficulty in pe rce iving the le sion, since only 56% of the le sions we re pe rce ive d by the patie nt. 29 De spite the tim e of ulce ration not be ing conside re d a statistically significant data as a risk factor for am putation, the pe riod of tim e de te cte d in this re se arch should be tak e n into conside ration, since it can indicate that the patie nts are tak ing too long to se e k de finitive tre atm e nt for the ir wounds. O ne of the possible e x planations for this de lay in the diagnosis could be the gre at num be r of patie nts com ing from the countryside (71%), including from the rural are a, whe re the basic he alth care is not com ple te ly structure d, be side s the low socioe conom ic and cultural le ve ls and poor hygie ne practice s. The re we re no statistically significant diffe re nce s be twe e n the m e an tim e of diagnosis of diabe te s m e llitus of patie nts with diabe tic foot (10 ye ars) and those who progre sse d to am putation, which was also 10 ye ars. Although Trautne r e t al. re port that the m e an duration of diagnosis of diabe te s in patie nts subm itte d to am putation was around 16 ye ars, 26 Ape lqvist e t al., whe n studying am putations and re curre nt ulce rs in patie nts with diabe tic foot or risk patie nts for a long tim e , ve rifie d that the re we re no significant diffe re nce s be twe e n the groups conside ring duration of the diabe te s, type of tre atm e nt and m e tabolic control. 13 Base d on the data e valuate d in this study, as we ll as on the indications to structure the care give n to the se patie nts in all he alth care le ve ls, the re is the ne e d of following not only the hospitalizations of pe ople with diabe tic foot, but also those who re ce ive basic and spe cialize d outpatie nt care . The re fore , it will be possible to de e pe n the analysis of the se and othe r clinical, e pide m iological and socioe conom ic variable s, with a highe r num be r of individuals and for a longe r tim e . This will allow not only to im prove the he alth diagnosis in this population, but also to m onitor the e volution of the m e asure s to be tak e n through inde x e s, e valuating the ir e fficie ncy and e fficacy and he lping to corre ct the im ple m e ntation of m e asure s that are ne ce ssary to change the re ality of the se pe ople .


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CONCLUSION The authors conclude that the se ve rity of le sions, the abse nce of both distal pulse s and age s ove r 60 ye ars we re conside re d pre disposing factors to pe rform am putation in patie nts with diabe tic foot and that, in the state of Se rgipe , the re is an e x agge rate d num be r of prim ary am putations in patie nts with diabe tic foot and abse nce of pulse s, who are not subm itte d to vascular re pairs that could save the se lim bs.

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