Pedal branch arterial bypass for limb salvage

In patients with critical lower extremity ischemia and occlusion of the distal tibial and pedal arteries bypasses to pedal artery branches may offer the only alternative to primary amputation. The results of 22 pedal branch arterial bypasses are reported, and a review of the literature is offered. The charts of 22 patients undergoing pedal branch arterial bypass during a 12-year period were retrospectively reviewed. The results of six additional reports of this technique were also evaluated. In the present series the cumulative primary graft patency rate was 72 per cent after 2 years. The cumulative limb salvage rate during this interval was 82 per cent. Similar graft patency and limb salvage rates were obtained with the approximately 200 other bypasses of this nature as reported in six other series. Pedal branch arterial bypass offers limb salvage results that are comparable to perimalleolar and pedal artery bypasses. In patients with critical limb ischemia and occlusion of distal tibial and pedal arteries, pedal artery branches should be sought as potential outflow sites. Bypasses to these arteries result in good long-term limb salvage, improved survival, and good functional ability for amputation. Pedal artery branch bypasses are a superior alternative to primary amputation.     

Graft occlusion following aortofemoral bypass for peripheral ischaemia

Over a 10-year period, 241 patients with non-aneurysmal aortoiliac disease underwent aortofemoral bypass to 476 limbs. Four patients (1.7 per cent) occluded their grafts within 30 days of surgery, while 25 (10.4 per cent) suffered late graft occlusion. Postoperative occlusions were associated with significant morbidity and only one patient avoided major limb amputation or death. Overall, 46 episodes of graft thrombosis involving 51 graft limbs were encountered, the most common underlying cause being pre-existing or progressive multilevel distal occlusive disease. The overall cumulative graft patency rates were 95 and 87 per cent at 1 and 5 years respectively. Cumulative 5-year patency was significantly higher in patients presenting with claudication (91 per cent) than in patients presenting with rest pain (77 per cent) or ulceration and/or gangrene (71 per cent). Patients with evidence of multilevel distal occlusive disease at the time of aortic surgery had a significantly higher incidence of occlusion compared with those in whom there was no significant distal disease. In 35 episodes of occlusion (76 per cent), surgery was undertaken to restore limb blood flow, being successful in all but one case, with the most commonly performed procedure being graft limb thrombectomy. Seven of 28 patients (25 per cent) ultimately required major limb amputation and three patients died as a direct consequence of graft thrombosis.     

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

OBJECTIVE: in diabetic patients with critical limb ischaemia (CLI) an inferior success rate following infrainguinal bypass surgery is quite often suggested. The aim of this retrospective analysis was, therefore, to evaluate the graft patency and, particularly, the clinical outcome at 1 year in diabetic compared with non-diabetic patients. MATERIAL AND METHODS: two hundred and eleven patients (diabetics 94; non-diabetics 117) with femorodistal reconstruction for CLI were studied. Groups were comparable with regard to the Fontaine classification, the distribution of vascular risk factors, graft material, distal anastomosis site, and the angiographic runoff grading. RESULTS: diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004). CONCLUSIONS: our preliminary results support the view that infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients.     

Axillofemoral bypass as a limb salvage procedure in high risk patients with aortoiliac disease

Thirty-eight patients presenting with severe limb ischaemia and considered unfit for major aortic reconstruction underwent axillofemoral bypass as a limb salvage procedure. Four patients (11 per cent) died, including two who had presented with bilateral ischaemia secondary to acute aortic occlusion. The operative mortality rate for patients presenting with rest pain or ulceration/gangrene was 6 per cent. Cumulative 5-year survival and limb salvage were 44 per cent and 86 per cent respectively. Graft occlusion was the principal cause of worsening symptoms during follow-up (5-year primary patency of 68 per cent) and accounted for all major amputations of the operated limb. Axillounifemoral grafts had a significantly worse 5-year patency (50 per cent) than axillobifemoral grafts (80 per cent, P less than 0.05) and three of five patients who developed worsening symptoms in the non-operated limb died or required a major limb amputation as a consequence. Axillofemoral bypass is a valuable alternative to major aortic reconstruction in elderly patients and allows a greater proportion to be offered reconstruction than would otherwise be possible.     

Distal bypass for limb salvage in very elderly patients

During the last 3 1/2 years, 40 bypasses to a tibial or peroneal artery (distal bypass) were performed for severe leg ischemia in 34 patients who were 80 years of age or older (range, 80-91; mean, 85). The operative mortality rate was 5 per cent. Cumulative life-table limb salvage rates for the 40 extremities were 91 per cent at 1 year and 81 per cent at 3 years. Graft patency rates at 1 and 3 years were 88 per cent and 56 per cent, respectively. Survival rates for the 36 patients were 91 per cent and 58 per cent at 1 and 3 years, respectively. Among 134 patients younger than 80 years who underwent 142 distal bypasses during the same 3 1/2-year period, no operative deaths occurred. In this younger group, cumulative life-table rates at 1 and 3 years were 89 per cent and 89 per cent, respectively, for limb salvage, 86 per cent and 85 per cent, respectively, for graft patency, and 93 per cent and 78 per cent, respectively, for survival. There were no statistically significant differences in these figures for the younger group when compared with corresponding figures for the older group. Among the 36 very elderly patients who underwent distal bypass for limb salvage, 24 patients (67%) with 25 revascularized limbs are alive and have a salvaged, functional extremity after follow-up as long as 41 months (mean, 21 months). These results suggest that an aggressive approach using distal bypass is warranted for limb salvage in very elderly patients.     

Aggressive arterial reconstruction for critical lower limb ischaemia.

A consecutive series of 315 patients underwent arterial reconstruction for 329 critically ischaemic lower limbs over a 5-year period. Patients were not excluded from limb salvage surgery on the basis of poor run-off on preoperative angiography. Femorocrural bypass to a single calf vessel was required in 239 limbs (73 per cent); the 30-day cumulative mortality rate was 7 per cent, rising to 41 per cent at 5 years. Cumulative graft patency at 30 days, 1 year, 2 years and 5 years was 96, 85, 84 and 82 per cent respectively and was independent of the level of reconstruction. In situ long saphenous vein was the conduit of choice for distal bypass but, when this was absent, satisfactory results were obtained with arm vein or composite vein grafts. Acceptable results can be obtained for reconstructive surgery without preoperative angiographic selection of patients. An aggressive approach to limb salvage is therefore justified.     

Lower limb revascularization with a new bioactive prosthetic graft: early and late results

The aim of the study was to evaluate the immediate and long-term results of femoropopliteal bypasses performed with a new bioactive heparin-treated expanded polytetrafluoroethylene (ePTFE) graft in a single-center experience. From March 2002 to April 2006, 51 patients underwent lower limb revascularization with a new bioactive ePTFE prosthetic graft with covalent end-point attachment of heparin to the graft surface. Data concerning preoperative assessment, intraoperative strategy, drug administration, and follow-up surveillance program were prospectively collected in a dedicated database; early results were analyzed in terms of graft patency, amputation rate, and deaths. Follow-up consisted of clinical and duplex scan examination at 1, 6, and 12 months and yearly thereafter. Midterm results in terms of primary and secondary patency, limb salvage, and survival were analyzed. Patients were predominantly male (35 patients, 71%), with a mean age of 71 years (SD = 9.05). Indications for surgical revascularization were critical limb ischemia in 36 patients and severe intermittent claudication in 15 patients. Interventions were performed for occlusion of a native vessel in 35 cases, whereas 12 patients had late thrombosis of a femoropopliteal bypass; the remaining four patients were operated on for an occluded popliteal artery aneurysm. Intervention consisted of below-knee bypass in 34 patients, while the other 17 had an above-knee revascularization. No perioperative deaths occurred. Cumulative 30-day graft patency was 88%, with an amputation rate of 4% (two cases). Results were similar in above- and below-knee revascularizatons. Mean duration of follow-up was 18 months (SD = 7). Cumulative estimated 24-month survival and primary patency rates were 97% and 80.2%, respectively; the corresponding limb salvage rate was 85.7%. Long-term results did not significantly differ in above- and below-knee revascularizatons. In our experience, the use of a modified ePTFE graft with covalent end-point linkage of heparin molecules on the graft surface provides good early and midterm results, with low rates of graft thrombosis and amputation.     

Die ischämische Form des diabetischen Fußsyndroms

In this review, direct and indirect methods of revascularisation in diabetics with ischaemic foot lesions are discussed. This work focuses on infrainguinal arterial reconstructions in diabetic patients with critical limb ischaemia, the frequency of which has increased rapidly during the last decade. Even though graft patency seems to be comparable with non-diabetics in modern series, an inferior clinical outcome is often assumed for the diabetics.The aim of this evaluation, in addition to discussing the technical aspect of graft permeability, is therefore to elucidate the clinical status of diabetic patients following infrainguinal arterial bypass surgery. For this purpose, the healing process of pedal lesions, limb salvage rate, and the survival in diabetics is analyzed and then compared with the clinical outcome in non-diabetics.     

Randomized clinical trial of distal anastomotic interposition vein cuff in infrainguinal polytetrafluoroethylene bypass grafting

BACKGROUND: The aim was to examine the effect of a Miller vein cuff at the distal anastomosis on the medium- to long-term patency and limb salvage rates of femoral to above-knee and femoral to below-knee popliteal artery polytetrafluoroethylene (PTFE) bypasses. METHODS: This study involved extended follow-up of the original cohort of patients included in a previously reported multicentre randomized clinical study. Outcome measures were bypass graft patency and limb salvage. RESULTS: Two hundred and sixty-one bypass operations were originally randomized. For this study, full data were available on 235 (120 with a Miller cuff, 115 without). The cumulative 5-year patency rate for above-knee bypasses with a Miller cuff was 40 per cent, compared with 42 per cent for non-cuffed bypasses (P = 0.702). The cumulative 3-year patency rate for below-knee bypasses with a Miller cuff was 45 per cent, compared with 19 per cent for non-cuffed bypasses (P = 0.018). A Miller cuff had no significant effect on limb salvage for above-knee or below-knee bypasses. CONCLUSION: Three-year patency rates of femoral to below-knee popliteal PTFE bypasses were improved by a Miller cuff. Miller cuffs had no effect on patency rates for femoral to above-knee popliteal bypasses at 5 years and did not improve limb salvage in either group.     

Limb salvage surgery in end stage renal disease: is it worthwhile?

The role of limb salvage surgery in patients with end stage renal disease (ESRD) is controversial. In view of this debate, we reviewed our experience with 54 primary and 15 secondary revascularizations for limb salvage in patients with ESRD over the past decade. Thirty-seven patients required dialysis and 10 had functioning renal transplants. Severe limb threatening ischemia was the indication for all revascularizations. The 2-year cumulative secondary graft patency rate was 56.2% with an associated limb salvage rate of 71.4%. There was no significant difference in graft patency or limb salvage rates between patients requiring dialysis and those with functioning renal allografts (p = 0.5). The 30-day operative mortality for the 99 surgical procedures (69 arterial bypasses and 30 additional operations) was 13% and the 2-year patient survival was 45.6%. Six of the 15 amputations were performed despite a patent graft on limbs which had extensive infection and gangrene. We conclude that limb salvage surgery should only be undertaken with recognition of these risks in patients with ESRD or functioning renal transplants. Surgery should be performed before gangrene and infection become extensive. Patients with unrelenting infection or mid-forefoot gangrene should be considered for primary amputation.     

In situ saphenous vein for lower extremity revascularization.

BACKGROUND. During a 6-year period, 349 in situ saphenous vein bypass grafts were performed for limb salvage by three surgeons. METHODS. Outflow anastomoses were constructed to the infrageniculate popliteal (25%), posterior tibial (20%), peroneal (20%), anterior tibial (19%), and dorsal pedal arteries (7%). Mean patient age was 70 1/2 years. RESULTS. The 30-day mortality rate was 3.2%, and 19% died during the ensuing 68-month interval. At 1, 24, and 60 months primary graft patency was 89%, 77%, and 74%, secondary graft patency was 91%, 80%, and 78%, and cumulative limb survival was 94%, 88%, and 84%, respectively. Cumulative patency rates at 60 months depending on outflow site were as follows: popliteal (85%), anterior tibial (80%), posterior tibial (70%), dorsal pedal (68%), and peroneal (60%). Patency at the peroneal position was significantly inferior to that of other infrapopliteal sites combined (p less than 0.05). Cumulative limb survival at 60 months, according to outflow site, was as follows: popliteal (95%), anterior tibial (85%), posterior tibial (78%), dorsal pedal (73%), and peroneal (67%). There was no significant difference in limb salvage among infrapopliteal outflow sites. However, patency rates and limb salvage were significantly better for the popliteal outflow site than the infrapopliteal outflow sites (p less than 0.01). CONCLUSIONS. (1) A 5-year graft patency rate of 78% and a limb salvage rate of 84% are achievable, (2) peroneal bypass is associated with a lower rate for graft patency but not limb salvage, and (3) popliteal bypass has the best graft patency and limb salvage rates.     

A decade of oral anticoagulant treatment to maintain autologous vein grafts for femoropopliteal atherosclerosis.

To determine whether long-term oral anticoagulant treatment was effective in improving graft performance and preventing major amputation following vein bypass surgery for femoropopliteal atherosclerosis, a clinical trial was conducted in one single center and continued during 10 years. After 130 patients had electively received a femoropopliteal vein graft, they were randomly assigned to a therapy group (treatment with phenprocoumon [n = 66]) or to a control group (n = 64) that remained without any anticoagulant treatment. Primary end points of the study were graft reocclusion and limb loss. The median durations of primary patency and limb salvage were significantly longer for treated patients than that for controls. In addition, survival in the therapy group was longer. Following autologous vein bypass surgery in the treated group, the results were superior in terms of graft patency, limb salvage, and survival.     

Revascularization of the leg using polytetrafluoroethylene: Cumulative patency in patients with claudication and limb salvage

Of 196 polytetrafluoroethylene bypass grafts in the leg, 113 were placed in the femoropopliteal and 83 in the femorotibial or femoroperoneal position. Claudication was the indication for 31 percent of the grafts, and 67 percent were done for limb salvage. Cumulative patency rates calculated by the life-table method for the femoropopliteal grafts were 66 percent at 1 year, 53 percent at 2 years, and 49 percent at 3 years. Corresponding patency rates for the femorotibial or peroneal grafts were 48, 44, and 36 percent, respectively. An analysis of factors influencing graft patency indicated that the best results were obtained with femoropopliteal grafts done for claudication in the presence of good distal runoff and grafts placed in limbs without previously failed grafts. Graft occlusion was most likely in distal bypasses for limb salvage and limbs with previously failed grafts. It is concluded that alternatives to PTFE bypass should be considered in those patients at greatest risk for graft occlusion. In patients who lack a satisfactory saphenous vein but who must have a bypass graft, polytetrafluoroethylene is an acceptable arterial substitute; however, thrombectomy or revision will be required to maintain patency in a high proportion of cases.     

Bypasses to tibial vessels using polytetrafluoroethylene as the solo conduit in a predominantly diabetic population

The authors reviewed the Vascular Surgery Registry at the Beth Israel Deaconess Medical Center between 1990 and 1996 and identified 45 patients (47 limbs) who underwent bypass with polytetrafluoroethylene alone to infra-popliteal vessels. This represented only 2.6% of total tibial bypasses performed during that time. Sixty-nine percent of patients had diabetes. Indication for bypass was limb salvage in 96% of patients. Primary and secondary patency rates at 30 days, 1, 3, and 5 years were 87%, 87%; 58%, 60%; 41%, 43%; and 36%, 39%; respectively. Limb salvage rates at 30 days, 1, 3, and 5 years were 91%, 68%, 63%, and 63%. Cumulative survival rates at 3 and 5 years, however, were 53%, and 42%. The 29 grafts (64%) that were postoperatively anticoagulated with sodium warfarin showed trends in improved primary patency (47% vs 19%, p = 0.07), secondary patency (49% vs 20%, p = 0.03), and limb salvage (67% vs 58%, p = 0.06), at 3 years. There were no significant differences between diabetics and non-diabetics except in a trend toward decreased patient survival at 3 and 5 years in the diabetic population. Postoperatively, there were no deaths but there were two (4.2%) major cardiac complications. These data support the judicious use of tibial vessel bypass using PTFE in selected patients for limb salvage when autologous vein is not available. Diabetic patients appear to have similar results to non-diabetics and the postoperative use of sodium warfarin is beneficial.     

Current indications for axillounifemoral and axillobifemoral bypass grafts

Revascularization of the lower extremities may require an axillofemoral bypass when an aortobifemoral bypass is contraindicated. Thirty-one patients underwent axillounifemoral and 59 had an axillobifemoral bypass, with a mortality rate of 9%. The indication for operation was limb salvage in 67%, intra-abdominal sepsis in 21%, and disabling claudication in 12%. Cumulative survival, patency, and limb salvage rates were determined by life-table analysis. The cumulative patency and limb salvage rates (with standard errors) at 3 years were 68% +/- 8% and 78% +/- 9%, respectively. When stratified for type of operation, axillobifemoral bypass had a superior patency rate compared with axillounifemoral bypass (log rank = 3.882, p less than 0.05). There was no significant difference when patients were stratified for diabetes (log rank = 2.213, p = no significance [NS]), operative indication (disabling claudication vs. limb salvage) (log rank = 0.0005, p = NS), or outflow (no profundaplasty vs. profundaplasty) (log rank = 2.011, p = NS). We conclude that axillofemoral bypass is a reasonable alternative for revascularization in high-risk patients or in those patients in whom a transabdominal approach is contraindicated. We recommend aggressive use of the profunda femoris artery when the superficial femoral artery is occluded to achieve optimal results.     

Femoral-tibial bypass for calcific arterial disease

Overt calcification of the recipient artery and outflow bed has been regarded as a poor prognostic factor for femoral-distal arterial bypass patency and subsequent wound healing. In order to determine the short- and long-term limb salvage and graft patency rates achieved in these patients, the records of 35 patients undergoing 38 attempted femoral-tibial bypasses to a calcified recipient artery were reviewed. Two patients were unreconstructable at the time of surgery. Thirty-one of the 36 operations (86 percent) were performed using in situ saphenous vein bypass techniques, 3 were performed with polytetrafluoroethylene (PTFE), 1 with a composite sequential, and 1 with a composite vein graft. Immediate limb salvage was achieved in 31 of 36 limbs (86 percent). Five early below-knee amputations (14 percent) were required, two due to graft thromboses and three due to progressive foot necrosis despite patent grafts. One patient (3 percent) died secondary to sepsis. Three-year primary graft patency and limb salvage rates did not differ significantly from bypasses to noncalcified vessels. Femoral-distal bypass in the presence of overt calcific arterial disease may be successfully accomplished and offers an excellent prognosis for long-term graft patency and limb salvage.     

Are there angiographic predictors of success for vein bypass to the peroneal artery?

In order to evaluate the effect of angiographic run-off upon peroneal artery autogenous vein bypass patency and subsequent limb salvage, 53 autogenous vein peroneal artery bypasses performed for ischemic tissue loss were reviewed. All preoperative angiograms were evaluated according to three separate angiographic scoring systems that previously had been designed to quantify the severity of runoff resistance. None of the three scoring systems predicted either early bypass occlusion and/or major amputation. The cumulative 18-month primary patency and 24-month secondary patency rates were 71% and 90%, respectively. The 24-month limb salvage rate was 81%. Initial and intermediate-term salvage of limbs with ischemic tissue loss can be achieved by peroneal artery bypass. Angiographic scoring systems were poor predictors of bypass failure or major amputation.     

Early experience with popliteal to infrapopliteal bypass for limb salvage

In an attempt to improve graft patency and limb salvage in patients with isolated tibial vessel and/or popliteal-tibial vessel occlusive disease, bypass grafts from the popliteal or distal superficial femoral artery to infrapopliteal arteries were used in patients requiring bypass for limb salvage. During a 2 1/2-year period, 23 patients with patent axial vessels and hemodynamically normal inflow to the level of the knee underwent such bypasses. Cumulative graft patency and limb salvage rates at 31 months were 84% and 70%, respectively. Five of the six patients who required below-knee amputation did so because of progressive gangrene in the presence of a patent bypass. Short bypasses between the popliteal and infrapopliteal arteries can significantly contribute to limb salvage in patients with tibial vessel occlusive disease and may be particularly useful in patients with saphenous veins too short for longer bypasses.     

The Dacron EXS graft: patency in femoropopliteal and femorotibial surgery

Choice of the most suitable synthetic graft for use in peripheral vascular surgery in the lower extremity is controversial. The knitted Dacron Velour Externally Supported (EXS) graft is a recently developed vascular prosthesis which promises to be effective and durable for use in femoropopliteal and femorotibial bypass surgery. Between 11/80 and 7/83, 56 grafts were implanted in 49 patients. Eight patients were lost to follow-up, leaving 46 grafts for which patency data was determined. The distribution of sites of distal anastomosis was as follows: 25% were to the popliteal artery above the knee, 50% were to the popliteal artery below the knee, and 25% were to the tibial or peroneal arteries. Graft occlusion was determined by loss of Doppler pulses, return of ischemic symptoms, or failure to visualize flow in angiograms. Overall cumulative patency rates, calculated by the life table method, were as follows: 81% at 6 months; 76% at 1 year; 68% at 2 and 2 and 1/2 years. There was no statistical difference in patency between above-knee and below-knee popliteal artery bypasses. Moreover, patency rates were similar for diabetics vs. non-diabetics, for patients operated on for claudication vs. limb salvage; and for patients who had sympathectomy vs. no sympathectomy. Patency rates for bypass to the tibial and peroneal vessels in this series were better than recently reported in the literature for other synthetic prostheses; i.e. 75% at 4 months and 1 year; 56% at 2 and 2 and 1/2 years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aortoiliac endarterectomy: an 11-year review

Fifty-seven patients underwent aortoiliac endarterectomy over an 11-year period, the majority (86 per cent) for disabling claudication. No patient died within 30 days of surgery, but nine patients suffered significant complications. The cumulative survival rate was 98 per cent at 1 year, and was 94 and 78 per cent at 5 and 10 years respectively. Cumulative operated segment patency rates were 92 per cent at 5 years and 68 per cent at 10 years. There was no significant difference in survival rates between patients who smoked after surgery and those who did not, but smokers had significantly worse rates for cumulative patency, limb failure and symptom status than non-smokers. Twenty-seven patients developed worsening symptoms during follow-up and 24 patients required secondary vascular intervention. Fourteen patients subsequently required aortofemoral bypass and the largest single cause of operated segment failure was recurrent disease in the external iliac artery. Our evidence suggests that, while aortoiliac endarterectomy should be considered in young patients with localized disease not involving the external iliac artery, those who do not fit these criteria should be considered for primary aortofemoral bypass. Regardless of the choice of operation, the chance of success is jeopardized if the patient continues to smoke.