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.     

Advanced limb salvage: Pedal artery interventions

Chronic limb-threatening ischemia (CLTI) is on the rise due to the increasing prevalence of diabetes, which is a significant cause of morbidity and mortality worldwide. Due to diabetes, many patients with CLTI present with a predominance of tibial and pedal artery disease. Despite best care, limb amputation cannot always be prevented. Surgical bypass has always been the mainstay in distal revascularization and limb salvage; however, many patients with CLTI have comorbidities, insufficient vein, and anatomic abnormalities that prevent them from undergoing surgery. As a result, endovascular therapies have increased over the last 2 decades and are providing revascularization options in these patients. Although most of the current endovascular literature has focused on above-ankle arterial interventions, recent studies have highlighted the feasibility, safety, and clinical importance of pedal artery interventions. These endovascular techniques hold promise in relieving ischemic pain, healing foot ulcers, reducing rates and extent of amputation, and improving patient functionality and quality of life. This review aims to comprehensively detail pedal artery interventions in terms of anatomy, technique, intraprocedural imaging, and outcomes. In addition, suggestions of when to perform pedal artery interventions and post-intervention surveillance options will be discussed.     

Pedal arterial bypass for limb salvage in patients with diabetes mellitus.

OBJECTIVE: to evaluate pedal bypass grafting in patients with diabetes mellitus with critical limb ischaemia. PATIENTS AND METHOD: from 1994 to 1999, 49 consecutive pedal bypass grafts were performed in 46 patients with a median age of 69 years (range 37-85 years). The incidence of insulin-dependent diabetes mellitus was 87%. The distal anastomosis was located at the dorsalis pedis artery in 36, at the inframalleolar posterior tibial artery in 9 and at the plantar artery in 4 cases, respectively. RESULTS: one patient died perioperatively. Two bypass occlusions and one major amputation accounted for a primary patency rate of 96% and a limb salvage rate of 98% at 30 days, respectively. During a median follow-up of 28 months (range 1-70 months), 21 patients died of nonrelated causes. Three additional graft occlusions and 4 major amputations were noted resulting in a primary patency rate of 89% and a limb salvage rate of 87% at 48 months, respectively. CONCLUSION: Pedal bypass grafting utilising the greater saphenous vein with in-situ technique is a reliable and effective procedure to achieve durable limb salvage in patients with diabetes mellitus.     

Pedal branch artery bypass: a viable limb salvage option

PURPOSE: We reviewed our experience with pedal branch artery (PBA) bypass to confirm the role of these target arteries for limb salvage and to identify patient and technical factors that may be associated with graft patency and limb salvage. METHODS: In this retrospective study we analyzed 24 vein grafts to PBAs performed from 1988 to 1998 for limb salvage in 23 patients who had no suitable tibial, peroneal, or dorsal pedal target arteries. These PBA grafts were compared with 133 perimalleolar posterior tibial, defined at or below the ankle, or dorsalis pedis bypass grafts performed contemporaneously; the Kaplan-Meier life table was used in the analysis of graft patency and limb salvage. Life table analyses and logistic regression analysis of prognostic patient variables were also performed. RESULTS: The PBA bypass represented 3% of infrainguinal revascularizations for chronic critical limb ischemia at our institution over the study period. Patients who received PBA bypasses were more likely to be male (92% vs. 69%, P =.02) with lower incidences of overt coronary artery disease (33% vs. 50%, P =.12) and stroke (0% vs 15%, P =.04), and a higher incidence of end-stage renal disease (21% vs 8%, P =.06) than those undergoing perimalleolar bypass. Seventeen percent of PBA bypasses were performed with the anterior lateral malleolar artery, a vessel not previously described as a common bypass target. Two-year primary patency and limb salvage for PBA versus perimalleolar bypass was 70% versus 80% (P =.16) and 78% versus 91% (P = .28), respectively. Patency and limb salvage rates were no different in bypasses with above-knee or below-knee inflow arteries. CONCLUSION: An autogenous vein bypass to the PBA, though rarely required, provides acceptable primary patency and limb salvage when compared with perimalleolar tibial artery bypass when no suitable, more proximal target arteries are available. The PBA bypass should be considered before major amputation is undertaken.     

Revisions of endoprosthetic reconstructions after limb salvage in musculoskeletal oncology

Of 91 limb-salvage procedures using prosthetic reconstructions because of primary or metastatic bone and soft-tissue tumors 26 revisions were performed in 16 patients. Revision was due to polyethylene wear (9 cases), aseptic loosening (8 cases), recurrent hip dislocation (3 cases), prosthetic stem fracture (2 cases), infection (2 cases), leg length discrepancy (1 case), and traumatic dislocation of a saddle prosthesis (1 case). The follow-up period for tumor control varied from 1.5 to 22 years with a median of 13.5 years. The follow-up period after the last revision operation varied from 0.5 to 12 years with a median of 3 years. At the last follow-up, the functional results had deteriorated compared with after the primary operation in 5 patients and had improved in 2 patients. In the remaining patients, the results did not change.     

Pedal bypass grafting on arteriographically invisible foot arteries detected by duplex ultrasound for limb salvage

AIM: In this study the long-term outcomes in patients undergoing pedal bypass grafting were evaluated and the risk of graft occlusion was related to whether, preoperatively, the pedal arteries were visualized by angiography or not and were only detected by duplex ultrasonography. METHODS: In 2000-2005, 81 pedal bypass grafts were performed in patients with chronic critical lower-limb ischemia, of which 54 (66.7%) had diabetes. Tissue loss (SVS/ISCVS-category 5) was recorded in 68 (84%) limbs and rest pain (SVS/ISCVS-category 4) in 13 (16%) limbs. In 24 limbs (29.6%) bypass grafts were implanted on the pedal arteries that had not been visualized by preoperative angiography, but had been detected only by duplex ultrasound. RESULTS: During the follow-up (median, 17 months; range, 3-69 months), 18 grafts (22.2%) failed. Seven limbs had to be treated by early thrombectomy, which resulted in long-term graft patency and limb salvage. The early postoperative mortality rate was 2.5%. Cumulative primary and secondary graft patency rates, and limb-salvage rates were 70.2%, 80.2% and 82.4%, respectively. No significant difference in graft occlusion was found between the patients with visible and those with not visible pedal arteries on preoperative arteriograms (Fisher's exact test). CONCLUSIONS: Duplex ultrasonography is a reliable modality for detection of target pedal arteries not visualized by preoperative arteriography and it helps reduce the number of patients with non-operable arterial occlusion disease by about 25%.     

Axillopopliteal bypass for limb salvage.

Forty-one axillopopliteal bypass grafts have been placed in 30 patients for limb salvage in the past 12 years. The mean patient age was 65.6 years; 8 were women; 19 smoked; and six had diabetes. Sixteen grafts were straight axillopopliteal bypass grafts, and 25 were sequential axillopopliteal bypass grafts. Cumulative life-table primary patency rates at 1, 2, and 3 years were 70%, 56%, and 43%, respectively; secondary patency rates were 73%, 57%, and 50%, respectively. Corresponding limb salvage rates were 86%, 69%, and 69%, respectively. Ringed polytetrafluoroethylene (PTFE) graft patency at 3 years was 61% versus 40% for unsupported PTFE grafts (p = 0.35). Ringed PTFE axillofemoral grafts with sequential femoropopliteal saphenous vein grafts had a 3-year patency of 67%. Graft patency was restored in 25% of occluded grafts by thrombectomy and in 80% of occluded grafts by thrombectomy with graft revision (p = 0.21). Cumulative 3-year patient survival was 48%. The 30-day operative mortality rate was 20%; patients operated on for graft infection had a 30-day operative mortality rate of 36%. The data support the use of axillopopliteal bypass for limb salvage when standard revascularization techniques are contraindicated. Long-term patency is enhanced by use of externally supported PTFE and sequential femoropopliteal saphenous vein.     

Profundoplasty for limb salvage

Profundoplasty was performed in 26 legs because of rest pain or gangrene; previous arterial reconstruction had been done in 12 of them. In 16 limbs the popliteotibial segment was patent; profundoplasty was successful in each case. In 10 limbs the popliteotibial segment was occluded, and profundoplasty failed in one instance. One patient died. The authors believe that re-establishing blood flow and pressure to the deep femoral artery, especially to the descending branch of the lateral circumflex artery and the distal part of the deep femoral artery can effectively improve the condition of ischemic legs.     

Outflow resistance measurement during infrainguinal arterial reconstructions: a reliable predictor of limb salvage

Criteria for abandoning infrainguinal arterial reconstructions in favor of major amputations should include reliable predictors not only of graft patency, but more importantly, of limb salvage. To evaluate the efficacy of intraoperative outflow resistance measurements in predicting limb salvage after infrainguinal bypasses, we have reviewed 134 such operations (64 femoropopliteal and 70 femorodistal bypasses) performed for critical ischemia. Outflow resistance measurements were divided into quartiles for femoropopliteal bypasses (Group A 0.17 mm Hg/ml/min or less, Group B 0.18 to 0.24 mm Hg/ml/min, Group C 0.25 to 0.4 mm Hg/ml/min, and Group D greater than 0.4 mm Hg/ml/min) and femorodistal bypasses (Group A 0.4 mm Hg/ml/min or less, Group B 0.4 to 0.58 mm Hg/ml/min or less, Group C 0.6 to 1 mm Hg/ml/min, and Group D 1 mm Hg/ml/min or greater). One year limb salvage rates for patients who underwent femoropopliteal bypass were 95 percent, 92 percent, 87 percent, and 67 percent from the lowest to the highest quartile (difference not statistically significant), and for those who had femorodistal bypass, they were 51 percent, 75 percent, 48 percent, and 0, respectively (p less than 0.05). Interestingly, 12 month graft patency and limb salvage rates for patients who underwent femorodistal bypass with outflow resistances between 0.59 and 1 mm Hg/ml/min did not correlate well (22 percent and 48 percent, respectively), whereas for those with outflow resistance greater than 1 mm Hg/ml/min, they were 22 percent and 22 percent, respectively. Thus, measurement of intraoperative outflow resistance is a very accurate predictor of limb salvage after infrainguinal bypass operations.     

Sequential femoral-tibial bypass grafting for limb salvage.

Bypass grafting to distal lower extremity vessels continues to be associated with a high rate of graft occlusion. By utilizing a sequential side-to-side anastomosis between saphenous vein and popliteal artery in femoral-tibial bypass grafts, runoff can be increased and graft patency thereby improved. Sequential femoral-tibial grafts were employed in seven patients with gangrene, trophic changes, or restpain, all of whom had single-vessel runoff by arteriography. All seven sequential grafts established to a distal vessel in addition to the popliteal artery have remained open for periods of five to 27 months as determined by palpable graft or foot pulses. Two patients undersent below-knee amputation within six months of operation but had patent grafts at the time of amputation. In three patients ischemic ulcers resolved and in two patients toe amputations healed successfully. Sequential bypass grafting is a technique aimed at improving the patency rate of femoral-tibial bypass grafts by augmenting runoff.     

Isolated profundaplasty for limb salvage

Fifty-four patients underwent 56 profundaplasties for limb salvage. All had stenosis greater than 50% in diameter of the deep femoral artery and associated superficial femoral artery occlusive disease. After profundaplasty, ischemic ulcers healed in 9 of 17 (53%) patients. Rest pain was relieved in 6 of 19 (32%) and areas of ischemic necrosis healed in 7 of 20 (35%). Cumulative patency of the deep femoral artery was 49% at 3 years but fell to 21% at 5 years, whereas cumulative limb salvage was 49% and 36%, respectively. Eleven of the required 28 amputations were performed in the immediate postoperative period. Profundaplasty was used to lower the amputation level and preserve the knee joint in six patients. The other five early amputations occurred in severely ischemic limbs without distal vessels suitable for bypass. The profundaplasty remained patent in all 19 patients who underwent below-knee amputation and 16 (84%) became ambulatory with a prosthesis. Hemodynamic data provided by determination of the profundapopliteal collateral index predicted limb salvage in 10 of 11 (91%) of limbs when the index value was less than or equal to 0.19. Other clinical criteria, such as preoperative ankle-brachial index and the presence of diabetes mellitus, had no predictive value. Isolated profundaplasty for limb salvage is an effective first procedure for selected patients and provides a reasonable alternative to primary amputation or high-risk distal bypass. When amputation is inevitable, effective perfusion of the profunda femoris artery is essential for preservation of the knee joint and results in a high degree of functional rehabilitation.     

Endovascular therapy for limb salvage

In recent years percutaneous therapy has gradually been adopted as an alternative to primary amputation in persons deemed unsuitable as surgical candidates, and has established itself as a primary mode of treatment. There has been an explosion in endovascular technology and a revolution in revascularization patterns for limb salvage. Open surgery is now frequently reserved for failure of endovascular attempts or pathology unsuitable for endovascular revascularization. This article aims to educate the practicing general surgeon about the usefulness and appropriate application of different therapeutic endovascular options as applied to limb salvage.     

Axillofemoral bypass for limb salvage

Objective : To evaluate the early and long‐term outcomes of axillofemoral bypass performed at a tertiary referral vascular centre over a 17‐year period. Methods : From 1982 to 1998, 30 patients underwent axillofemoral bypass at the University of Hong Kong Medical Centre. A retrospective analysis of all these records was undertaken. Data on demographic features and results of surgical intervention were reviewed. Early outcomes were analyzed with respect to morbidity, mortality and improvement of clinical category (according to the Reporting Standards of the Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery). Long‐term outcomes were documented with respect to graft patency, patient survival and limb loss rates. Results : Clinical success was achieved in 22 patients (73%) after operation. The postoperative morbidity and mortality rates were 30% and 20%, respectively. The primary patency of axillofemoral bypass was 62%, 51% and 45% at 1, 2 and 3 years, respectively. Limb loss rate was 23% at 3 years. The cumulative survival rate of the study population was 67%, 57% and 57% at 1, 2 and 3 years, respectively. Conclusions : Axillofemoral bypass is a valuable limb‐salvaging surgical option for revascularization of lower limbs in high‐risk patients with aorto‐iliac occlusive disease.