编织型镍钛合金支架治疗慢性严重肢体缺血的多中心回顾性研究

目的探讨编织型镍钛合金Supera支架治疗的慢性严重肢体缺血(CLTI)患者的中长期疗效。方法回顾性分析 2017年4月至2020年12月复旦大学附属中山医院血管外科、上海市中西医结合医院脉管病科及浙江省温岭市中医院血管外科3家中心采用Supera支架治疗的303例50岁以上CLTI患者的临床资料。其中男性205例, 女性 98例;年龄(73.5±9.3)岁。电话随访并收集患者生存情况、临床驱动的靶病变血运重建(CD-TLR)、大截肢和创面愈合情况。采用Kaplan-Meier法绘制生存曲线, 以Log-rank检验比较两组患者的生存差异。结果 296例患者获得随访, 随访时间为(23.6±12.9)个月。Kaplan-Meier生存曲线显示术后 6、12、24及36个月总生存率分别为99.0%、96.2%、86.1%、77.4%。术后12、24和36个月免于CD-TLR率分别为94.2%、91.1%和89.6%。随访期内, 15例患者接受了大截肢, 总保肢率为92.7%(281/303), 有效保肢率为94.9%(281/296)。268例术前存在创面的患者中, 203例愈合, 创面...     

负压创面引流技术在糖尿病足治疗中的作用

目的 分析应用负压创面引流技术和常规敷料治疗糖尿病足溃疡创面的疗效.方法 回顾性分析2008年5月至2010年5月在我院治疗的35例Wagner 3～5级糖尿病足患者资料.20例接受常规敷料治疗;15例接受负压创面治疗.通过创面愈合时间及截肢率评价疗效.结果 负压创面组平均创面愈合时间为(28.21±4.34)d,常规敷料组为(57.35±5.23)d.常规敷料组18例截肢,截肢率为90.00%,2例(10%)接受常规敷料治疗患者保肢成功,而负压创面组5例截肢,截肢率为33.33%,10例(86.67%)患者保留患肢功能.结论 负压创面治疗技术结合清创及适当的抗炎治疗,可以有效的降低糖尿病足患者的截肢率.     

经皮微创胫骨截骨横向骨搬移术治疗糖尿病足

[目的]探讨应用经皮微创胫骨横向骨搬移术治疗糖尿病足的临床疗效。[方法]选取2015年6月~2016年10月按Wagner诊断标准确诊为患有Ⅲ~Ⅳ期糖尿病足的糖尿病患者23例23足,采取胫骨横向骨搬移手术治疗;记录手术时间、术中失血量、术后并发症,通过观察糖尿病足创面愈合率、1年后保肢率评价疗效,比较手术前后足部皮温、VAS评分、Barthel指数评分,部分患足手术前后DSA评估血运。[结果]所有患者手术顺利,手术时间(45.92±6.03)min,术中失血量(30.12±4.15)ml,1例WagnerⅢ期患者截肢,1例WagnerⅣ期患者死于心衰。21例患者获得随访,随访时间12~19个月,平均(14.51±0.32)个月;WagnerⅢ期创面愈合率及1年后保肢率均为92.86%,WagnerⅣ期创面愈合率及1年后保肢率均为88.89%,两分期创面愈合率及1年后保肢率均无明显差异(P0.05);与术前相比较,术后足部皮温显著升高(P0.05)、术后VAS评分显著降低(P0.05)、术后Barthel指数评分显著升高(P0.05)。有9例患者进行了手术前后患足DSA检查,结果显示所有患者的搬移骨块周围形成了较多的毛细血管,足部动脉增粗清晰显示,血流明显加快。[结论]胫骨横向骨搬移术能促进糖尿病足创面的愈合,避免或延长患足的截肢率。     

腔内介入治疗膝下动脉缺血性疾病

目的 回顾性分析血管腔内介入治疗膝下动脉缺血性疾病的疗效,初步总结其技术要点、主要并发症防治与应用价值.方法 对2004年11月至2007年7月期间收治的60例(65条肢体)膝下动脉缺血性疾病的患者行膝下病变段动脉球囊扩张(percutaneous transluminal angioplasty,PTA)和/或支架植入(stenting)治疗,观察症状的改善,踝肱指数(ankle/brachial index,ABI)的变化,保肢率以及近期通畅率.结果 60例患者(65条肢体)中,技术成功51例,成功率83.3%;临床成功53例,成功率88.3%.症状完全缓解40例(66.7%),部分缓解13例(21.7%),无改善7例(11.6%);ABI从术前0.40±0.18增加到术后0.91±0.22,两者差异有统计学意义(P＜0.01).2例膝下截肢,4例足趾截趾,出院时保肢率为91%.随访54例,随访时间10 d至30个月,平均(14.5±1.2)个月.2例膝上截肢,2例膝下截肢,2例足趾截趾,保肢率88.9%(48例/54例);症状复发5例,复发率9.2%,血管再闭塞或再狭窄10例,通畅率81.5%,1年累积通畅率为57.3%.结论 腔内介入治疗膝下动脉缺血性疾病安全、可行,近期疗效确切,是该类疾病重要的治疗选择.     

膝下血管成形术治疗重症肢体缺血的临床疗效

目的评价膝下经皮腔内血管成形术(PTA)治疗重症肢体缺血(CLI)的临床疗效。方法回顾性分析48例(50条患肢)接受膝下PTA治疗的下肢CLI患者,统计PTA的技术成功率、围术期并发症、PTA术后的缺血症状缓解情况、治疗血管的通畅情况和大截肢情况。结果共针对64条膝下动脉施行PTA,技术成功率为85.94%(55/64);围术期并发症发生率为12.50%(6/48)。平均随访(16.25±2.65)个月;PTA术后1、3、6、12、24、36个月的1期血管通畅率分别为92.0%、85.7%、79.0%、75.8%、59.8%、29.9%;保肢率分别为92.0%、92.0%、89.7%、86.4%、82.1%、72.9%。50条患肢中,1、3、6个月时的缺血症状缓解率分别为42.00%(21/50)、70.21%(33/47)和86.36%(38/44)。结论膝下PTA治疗CLI技术可行,安全性高,能有效缓解CLI的静息痛症状、促进肢体溃疡的愈合,避免大截肢的发生。     

SilverHawk斑块切除系统治疗膝下动脉硬化闭塞

目的探讨SilverHawk斑块切除系统治疗膝下动脉硬化闭塞的临床效果。方法采用SilverHawk斑块切除系统治疗34例(39条患肢)膝下动脉硬化闭塞患者,观察治疗效果及随访结果。结果患者围手术期无死亡。39条患肢中,31条(28例患者)顺行开通成功,8条(6例)逆行开通成功,治疗成功率100%(39/39),技术成功率92.31%(36/39)。术后1周患者跛行距离、趾肱指数(TBI)及踝肱指数(ABI)均高于术前(P均0.05)。术后随访2～46个月,平均(23.63±9.71)个月,溃疡愈合率90.00%(9/10);4条坏疽患肢中,1条膝下截肢。术后6、12、24个月患肢一期通畅率分别为87.18%(34/39)、82.05%(32/39)及71.79%(28/39),二期通畅率分别为94.87%(37/39)、92.31%(36/39)和84.62%(33/39)。结论采用SilverHawk斑块切除系统治疗膝下动脉硬化闭塞效果良好。     

负压封闭引流技术对断肢(指)再植术后患者创面修复的影响

目的比较负压封闭引流技术(VSD)和传统换药对断肢(指)再植患者术后创面的疗效。方法将2010年10月~2014年10月我科收治的121例患者132个断肢(指)再植手术的患者随机分为两组,VSD组69个肢体,术后应用VSD治疗;传统换药组63个肢体,应用传统换药治疗。观察两组患者术后截肢率、创面愈合时间和治疗费用。结果对121例患者随访10~12个月,平均11个月。69个再植肢体术后应用VSD的患者截肢5个,截肢率为7.2%,创面愈合时间11.6~23.2天,平均(16.6±2.5)天;传统换药组63个再植肢体术后截肢11个,截肢率17.5%,创面愈合时间20.3~30.2天,平均(25.6±4.5)天。在断(指)肢再植术后,VSD组和传统换药组患者截肢率和创面愈合时间比较,差异有统计学意义(P0.05)。结论断肢(指)再植术后应用VSD可降低截肢率,减少住院费用,缩短住院时间。     

老年重症糖尿病足坏疽截肢的围手术期治疗分析

目的:探讨老年重症糖尿病足坏疽截肢的围手术期治疗方法。方法:自2002年6月-2005年6月手术治疗糖尿病足坏疽截肢48例,男28例,女20例;年龄60～84岁,平均73岁。46例单侧下肢截肢,2例双侧下肢截肢。膝上截肢29肢,膝下截肢18肢,半足截肢3足。按Waganer分类:Ⅳ级26例,Ⅴ级22例。结果:48例中愈合46例,死亡2例。其中甲级愈合44例,甲级愈合率88%。心肌梗死1例,脑梗死1例。术后残端坏死2例,创面感染2例。结论:老年重症糖尿病足坏疽截肢存在高危险性,良好的围手术期处理和准确判断截肢平面是手术成功的关键。     

重症下肢动脉缺血的诊治

目的 探讨重症下肢动脉缺血的手术治疗效果.方法 回顾性分析123例(137侧肢体)重症下肢缺血(Fontaine Ⅳ期)患者的治疗方法 及疗效,患者平均年龄(74±9)岁,男79例,女44例,33.33%有吸烟病史,43.09%合并冠心病,50.41%合并高血压,29.27%合并脑血管病,52.33%合并糖尿病.其中介入治疗15侧肢体,手术治疗118侧肢体,介入联合手术治疗4侧肢体.结果 围手术期死亡率4.88%.随访率88.89%,随访时间2～74个月,平均(18±18)个月,随访期间死亡率13.01%.术后1、2、3年通畅率分别为(81±4)%、(68±6)%、(61±7)%.动脉闭塞25例,再手术4例,截肢9例.溃疡或坏死创面术后半年愈合率78.85%(82/104),1年愈合率83.65%(87/104).术后1、2、3年保肢率分别为(81±4)%、(71±5)%、(65±6)%.结论 重症下肢动脉缺血患者通过介入及或手术方法 动脉重建可以达到满意的血管通畅率,促进创面愈合,降低截肢平面,提高保肢率.     

膝下动脉腔内成形术治疗严重下肢缺血

目的观察膝下动脉腔内成形术治疗严重下肢缺血的疗效。方法对2004年10月至2006年5月采用腔内成形术治疗的41例患者共48条患肢的资料进行回顾性分析。26条患肢有静息痛(54.2%);9条患肢发生足部溃疡(18.7%),13条患肢合并有足趾或足部组织坏疽(27.1%)。19条患肢踝肱指数(ankle/brachial index,ABI)为0,22条患肢在0.1～0.5之间,7条患肢在0.51～0.6之间。结果技术成功率为93.8%。术后33条患肢疼痛缓解(73.3%),其中27条患肢无疼痛(64.3%)。10条患肢症状减轻(22.2%),其中3条复发。足部溃疡的9条患肢中,1条患肢足部小溃疡愈合。13条足趾或足部组织坏疽的患肢,2条行膝下截肢,2条行半足截除。24条患肢术后ABI增加0.5以上,12条增加0.31～0.5,7条增加0.1～0.3。42条患肢被随访,随访率为93.3%;时间平均为8.5个月(1～18个月)。本组共截肢5条患肢,总救肢率为88.1%。结论膝下小动脉腔内成形术在无法接受动脉旁路移植的严重下肢缺血的患者可以作为首选治疗方法。     

Outcomes of a bypass-first strategy in chronic limb-threatening ischemia based on the Global Vascular Guidelines

ObjectiveThe Global Vascular Guidelines (GVGs) recommend initial revascularization (bypass or endovascular therapy) for chronic limb-threatening ischemia (CLTI) based on anatomical complexity and limb severity. This decision is made based on a prediction of the outcomes after endovascular intervention. This study was performed to evaluate outcomes after distal bypass in cases recommended for GVG bypass.MethodsA total of 239 distal bypasses for CLTI were evaluated in 195 patients with a GVG bypass recommendation treated between 2009 and 2020 at a single center in Japan. Comparisons were made between crural and pedal bypass cases.ResultsThe 195 patients (median age, 77 years; 67% male) underwent 133 crural bypasses (106 patients; 54%) and 106 pedal bypasses (89 patients; 46%). Hemodialysis was more common in pedal cases than in crural cases (P = .03). Hospital deaths occurred in two cases (1%) within 30 days. The whole cohort has a follow-up rate of 96% over a mean of 28 ± 26 months, with 3-year limb salvage rates of 87% and 3-year primary, assisted primary, and secondary patency rates of 40%, 65%, and 67%, all without significant differences between crural and pedal cases. The 1-year wound healing rate was 88% and tended to be higher in crural cases than in pedal cases (P = .068). The 3-year survival rate was 52% in the cohort and did not differ significantly between crural and pedal cases.ConclusionsPatients with CLTI with a GVG bypass recommendation had acceptable limb salvage, graft patency, wound healing, and survival after distal bypass, regardless of the bypass method. These findings indicate that a GVG bypass recommendation as an initial revascularization method is valid in the real world.     

Distal wound complications following pedal bypass: Analysis of risk factors

Wound complications of the pedal incision continue to compromise successful limb salvage following aggressive revascularization. Significant distal wound disruption occurred in 14 of 142 (9;8%) patients undergoing pedal bypass with autogenous vein for limb salvage between 1986 and 1993. One hundred forty-two pedal bypass procedures were performed for rest pain in 66 patients and tissue necrosis in 76. Among the 86 men and 56 women, 76% were diabetic and 73% were black. All but eight patients had a history of diabetes and/or tobacco use. Eight wounds were successfully managed with maintenance of patent grafts from 5 to 57 months. Exposure of a patent graft precipitated amputation in three patients, as did graft occlusion in an additional patient. One graft was salvaged by revision to the peroneal artery and one was covered by a local bipedicled flap. Multiple regression analysis identified three factors associated with wound complications at the pedal incision site: diabetes mellitus (p=0.03), age >70 years ( p =0.03), and rest pain ( p =0.05). Ancillary techniques (pie-crusting) to reduce skin tension resulted in no distal wound problems among 15 patients considered to be at greatest risk for wound breakdown. Attention to technique of distal graft tunneling, a wound closure that reduces tension, and control of swelling by avoiding dependency on and use of gentle elastic compression assume crucial importance in minimizing pedal wound complications following pedal bypass.Presented at the Nineteenth Annual Meeting of the Peripheral Vascular Surgery Society, Seattle, Wash., June 5, 1994.     

Limb salvage after successful pedal bypass grafting is associated with improved long-term survival

OBJECTIVES: Assessments of outcome after reconstruction for critical limb ischemia frequently ignore functional result and long-term morbidity and mortality. This study was undertaken to identify factors affecting long-term clinical outcome and survival after pedal bypass grafting. METHODS: The clinical data of 256 consecutive patients who underwent pedal bypass grafting for critical limb ischemia over a 12-year period were retrospectively analyzed. RESULTS: A total of 174 men and 82 women (median age, 70 years; range, 30-91 years) underwent 280 pedal bypass graft placements with autologous vein. Seventy-five percent of the patients were diabetic, and 20% had renal insufficiency (serum creatinine level > 2 mg/dL). The in-hospital mortality rate was 1.6% (4/256). The mean follow-up was 2.7 years (range, 0.1-10.1 years). Rates of primary and secondary patency, limb salvage, and survival at 5 years were 58%, 71%, 78%, 60%, respectively. A total of 160 limbs (57%) required additional interventions. Nineteen early graft thrombectomies/revisions and nine early amputations were performed. One hundred thirty-eight late interventions included 31 graft salvage procedures, 27 wound debridements, and 34 minor and 42 major amputations. At last follow-up or death, 219 (78%) limbs were being used for ambulation. End-stage renal disease (ESRD) and composite vein grafts predicted limb loss (P <.001, P <.001, respectively). Overall survival at 5 years was 60%. Survival after amputation was 79%, 53%, and 26% at 1, 3, and 5 years. Amputation and ESRD predicted higher mortality (P =.014, P =.0001, respectively). CONCLUSIONS: Pedal bypass grafting resulted in good functional limb salvage, but at the expense of multiple interventions in more than half the cases. ESRD and composite vein graft were associated with poor long-term limb salvage. Amputation after bypass grafting was associated with significantly worse long-term survival.     

Multidisciplinary approach achieves limb salvage without revascularization in patients with mild to moderate ischemia and tissue loss

ObjectiveThe Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system has been validated to predict wound healing and limb salvage of patients with peripheral artery disease (PAD). Our goal was to evaluate the association between WIfI stage and wound healing, limb salvage, and survival in a select cohort of patients with PAD and tissue loss undergoing an attempt of wound healing without immediate revascularization (conservative approach) in a multidisciplinary wound program.MethodsVeterans with PAD and tissue loss were prospectively enrolled in our Prevention of Amputation in Veterans Everywhere (PAVE) program. Limbs were stratified to a conservative, revascularization, primary amputation, and palliative limb care approach based on the patient's fitness, ambulatory status, perfusion evaluation, and validated pathway of care. Rates of wound healing, wound recurrence, limb salvage, and survival were retrospectively analyzed by WIfI clinical stages (stage 1-4) in the conservative group. Cox regression modeling was used to estimate clinical outcomes by WIfI stage.ResultsBetween January 2006 and October 2017, there were 961 limbs prospectively enrolled in our PAVE program. A total of 233 limbs with 277 wounds were stratified to the conservative approach. WIfI staging distribution included 19.7% stage 1, 20.2% stage 2, 38.6% stage 3, and 21.5% stage 4. All ischemia scores were classified as 1 or 2. Advanced wound interventions and minor amputations were performed on 40 limbs (16.6%) and 57 limbs (23.7%), respectively. Average long-term follow-up was 41.4 ± 29.0 months. Complete wound healing without revascularization was achieved in 179 limbs (76.8%) during 4.4 ± 4.1 months. Thirty-four limbs (14%) underwent deferred revascularization because of a lack of complete wound healing. At long-term follow-up, wound recurrence per limb was 39%. Overall limb salvage at long-term follow-up was 89.3%. Stratified by WIfI stage, there was no statistically significant difference between groups for wound healing (P = .64), wound recurrence (P = .55), or limb salvage (P = .66) after adjustment for significant patient, limb, and wound characteristics.ConclusionsIn select patients with mild to moderate ischemia and tissue loss, a stratified approach can achieve acceptable rates of wound healing and limb salvage, with limited need for deferred revascularization. WIfI clinical staging did not predict wound healing, limb salvage, or survival in this cohort.     

Limb salvage in diabetic foot syndrome with pedal bypass using the in-situ technique

INTRODUCTION: Treatment of the ischemic diabetic foot syndrome still represents a medical and economic challenge. Contrary to the aims of the Saint Vincent declaration a dramatic reduction of major amputations in Germany was not noted, although in the diabetic patients the predominant type of tibial artery occlusion allows construction of pedal bypasses for limb salvage. METHOD: In patients with ischemic diabetic foot syndrome following angiographic evaluation of the ischemic limb, the indication for surgical revascularisation of patent pedal arteries was established. The in-situ technique was preferred in the presence of a suitable ipsilateral greater saphenous vein whenever possible. Revascularisation was followed by treatment of foot ulcerations or, if necessary, minor amputations. Patients were followed by clinical examination and duplex scan investigation of the bypass in regular intervals. RESULTS: From 01/89 to 12/01 in 79 patients (59 men and 20 women) with non healing ulcerations or established gangrene from a total of 175 pedal bypasses 84 pedal bypass operations in 84 limbs were performed using the in-situ technique. All patients were diabetic and in addition 13.9% were dependent on hemodialysis for end stage renal disease. 59.5% of the bypasses originated from the popliteal artery (distal origin bypass). The dorsalis pedis artery was chosen for the distal anastomosis in 83% and the posterior tibial artery in 17%. Two patients (2.4%) died postoperatively from cardiac events. Early bypass occlusion occurred in 8.4% resulting in a major amputation rate of 6%. After 60 months primary, primary assisted and secondary patency was 67.7%, 71.5% and 75.3% respectively with a limb salvage rate of 78%. CONCLUSION: Pedal bypass using the in-situ technique provides excellent long term limb salvage rates in a disease with a generally unjustified bad prognosis with respect to limb salvage.     

Realistic expectations for pedal bypass grafts in patients with end-stage renal disease

Purpose: Limb-threatening ischemia in patients with end-stage renal disease (ESRD) represents a challenging clinical problem. Multiple series have shown the inferior limb salvage rate for femoropopliteal or femorotibial bypass grafts in this group. This outcome study is restricted to those patients with ESRD who require pedal bypass grafts for attempted limb salvage. Methods: Between December 1, 1990, and December 31, 1997, 34 patients with ESRD underwent pedal bypass grafting on 41 limbs. This review explores the patient and bypass graft outcomes and their relationships to typical risk factors. Results: The average age in the study was 64 years (range, 39 to 85 years). Twenty patients (59%) were men, 31 (91%) had diabetes, 32 (94%) were hypertensive, and 28 (82%) had coronary artery disease, but only 10 patients (29%) were smokers. All the patients were undergoing dialysis except 2 patients with functioning renal transplants. All bypass grafting procedures were performed for limb salvage. The follow-up periods ranged from 1 to 84 months (average, 13.5 months). With life-table analysis, the cumulative assisted primary patency rate was 62% at 1 year and 62% at 2 years. The limb salvage rate was 56% and 50% at 1 and 2 years, respectively. All the patients who were seen with heel gangrene had early limb loss or died. Seven of the 16 amputations (44%) were performed despite patent bypass grafts. Ten of the 16 amputations (63%) occurred within 3 months of the surgery. The survival rate was 64% at 1 year and 52% at 2 years. After the bypass graft procedure, the mean ankle brachial index and the toe pressure rose from 0.48 to 1.05 and 18 to 86, respectively. Conclusion: Modest success can be expected with pedal bypass grafts in patients with ESRD, with most failures occurring in the first 3 months. Limb salvage rates lag behind graft patency rates because of progressive necrosis despite a hemodynamically functioning bypass graft. Heel gangrene is a strong predictor for a negative outcome. Lastly, overall patient survival rates are poor but comparable with the rates of other patients with ESRD. (J Vasc Surg 1998;28:976-83.)     

Patient recovery after infrainguinal bypass grafting for limb salvage

Purpose: The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. Methods: The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. Results: The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. Conclusions: Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent. (J Vasc Surg 1998;27:256-66.)     

Role of aorto(bi)femoral bypass in treatment of patients with critical limb threatening ischemia

PurposeTo analyse the long-term outcome of open aortic procedures in patients with critical limb threatening ischemia.MethodsRetrospective analysis of all patients with aortoiliac TransAtlantic Inter-Society Consensus II (TASC II), type D (TASC D) lesions extending to the femoral artery who underwent aortic bypass procedures for critical limb threatening ischemia (CLTI) or intermittent claudication (IC).ResultsOver a period of 10 years, 87 patients with IC and 45 patients with CLTI received a total of 56 aortounifemoral and 76 aorto-bi-femoral bypass procedures. After 7 years, overall primary patency (82.2% [CLTI] vs. 80.5% [IC], p = .918) and overall secondary patency (88.9% [CLTI] vs. 88.5% [IC], p = .851) were similar between patients with CLTI and those with IC. Long-term-survival (66.7% vs. 71.3%, p = .356) as well as limb salvage (86.7% vs. 94.3%, p = .104) was considerably lower in the CLTI-group, but the difference was not statistically significant. In the subgroup analysis, patients with CLTI and ischemic lesions (Rutherford class 5–6) had the poorest outcome after 84 months, in terms of secondary patency (92.1% vs. 73.7%, p = .015), limb salvage (97.4% vs. 73.7%, p = .000), and long-term survival (75.0% vs. 26.3%, p = .000) compared to patients with IC. Multivariate analysis revealed significant associations for patients with Rutherford class 5–6 in terms of secondary patency (p = .037) and limb salvage (p = .015). There was a significant difference in primary patency between graft limbs with superficial femoral artery occlusion and graft limbs with patent superficial femoral artery (84.6% vs. 93.0%, p = .017).ConclusionsAortic bypass procedures can be used in the treatment of patients with CLTI. Moreover, results are satisfactory in patients with ischemic rest pain. However, less invasive treatments should be considered for patients with ischemic lesions.     

Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia

OBJECTIVE: To examine wound healing and the functional natural history of patients undergoing infrainguinal bypass with reversed saphenous vein for critical limb ischemia (CLI). METHODS: Consecutive patients undergoing infrainguinal bypass for CLI were retrospectively entered into a technical and functional outcomes database. The patients were enrolled from the tertiary referral vascular surgery practices at the University of Colorado Health Sciences Center and Southern Illinois University Medical School. Main outcome variables included wound healing, self-assessed degree of ambulation (outdoors, indoors only, or nonambulatory), and living status (community or structured) after a mean follow up of 30 +/- 23 months. These outcome variables were assessed relative to the preoperative clinical characteristics (symptom duration before vascular consultation, lesion severity, and serum albumin level) and graft patency. RESULTS: From August 1997 through December 2004, 334 patients (253 men; median age, 68 years) underwent 409 infrainguinal bypasses (157 popliteal, 235 tibial, and 17 pedal) for CLI (159 Fontaine III and 250 Fontaine IV). Perioperative mortality was 1.2%. At 1 and 3 years, respectively, the primary patency was 63% and 50%, assisted primary patency was 80% and 70%, limb salvage was 85% and 79%, and survival was 89% and 74%. Complete wound healing at 6 and 12 months was 42% and 75%, respectively. Thirty-four patients (10%) died before all wounds were healed. Multivariate analysis indicated that extensive pedal necrosis at presentation independently predicted delayed wound healing (P < or = .01). At baseline (defined as the level of function within 30 days before the onset of CLI), 91% of patients were ambulatory outdoors, and this decreased to 72% at 6 months (P < or = .01). Similarly, 96% of patients lived independently at baseline, and this decreased to 91% at 6 months (P < or = .01) Graft patency was associated with better ambulatory status at 6 months. A longer duration of symptoms before vascular consultation was associated with a worse living status at 6 months. CONCLUSIONS: Despite achieving the anticipated graft patency and limb salvage results, 25% of patients did not realize wound healing at 1 year of follow-up, 19% had lost ambulatory function, and 5% had lost independent living status. Prospective natural history studies are needed to further define the functional outcomes and their predictors after infrainguinal bypass for CLI.     

Efficacy of dorsal pedal artery bypass in limb salvage for ischemic heel ulcers.

PURPOSE: Although pedal artery bypass has been established as an effective and durable limb salvage procedure, the utility of these bypass grafts in limb salvage, specifically for the difficult problem of heel ulceration, remains undefined. METHODS: We retrospectively reviewed 432 pedal bypass grafts placed for indications of ischemic gangrene or ulceration isolated to either the forefoot (n = 336) or heel (n = 96). Lesion-healing rates and life-table analysis of survival, patency, and limb salvage were compared for forefoot versus heel lesions. Preoperative angiograms were reviewed to evaluate the influence of an intact pedal arch on heel lesion healing. RESULTS: Complete healing rates for forefoot and heel lesions were similar (90.5% vs 86.5%, P =.26), with comparable rates of major lower extremity amputation (9.8% vs 9.3%, P =.87). Time to complete healing in the heel lesion group ranged from 13 to 716 days, with a mean of 139 days. Preoperative angiography demonstrated an intact pedal arch in 48.8% of the patients with heel lesions. Healing and graft patency rates in these patients with heel lesions were independent of the presence of an intact arch, with healing rates of 90.2% and 83.7% (P =.38) and 2-year patency rates of 73.4% and 67.0% in complete and incomplete pedal arches, respectively. Comparison of 5-year primary and secondary patency rates between the forefoot and heel lesion groups were essentially identical, with primary rates of 56.9% versus 62.1% (P =.57) and secondary rates of 67.2% versus 60.3% (P =.50), respectively. CONCLUSION: Bypass grafts to the dorsalis pedis artery provide substantial perfusion to the posterior foot such that the resulting limb salvage and healing rates for revascularized heel lesions is excellent and comparable with those observed for ischemic forefoot pathology.