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.     

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.     

Redo Pedal Bypass Surgery after Pedal Graft Failure: Gain or Gadget?

Pedal bypass failure is not always associated with limb loss. Management of critical limb ischemia after failure is controversial. The aim of this study is to evaluate the results of redo bypass procedures to foot arteries in the absence of alternative tibial outflow arteries. Data of patients undergoing redo pedal bypass within a 14-year period were reviewed. The outcome after redo pedal bypass in patients whose original pedal bypass failed within 30 days versus those in patients whose original pedal bypass failed more than 30 days after the original pedal bypass were reviewed. Society for Vascular Surgery reporting standards were applied. Out of 335 pedal bypass grafts, 22 (6.6%) pedal redo bypass procedures were identified in 20 patients performed after previous pedal graft failure: 64% were male, mean age 67.7 +/- 9.5 years, diabetes 90.9%, hypertension 90.9%, coronary disease 68.2%, renal disease 18.2%. Seven patients were operated for early failure and 15 for late failure (median 193 days). The graft conduit at the first operation was ipsilateral greater saphenous vein (GSV) in 18 (81.8%), alternative vein in three (13.6%), and one expanded polytetrafluoroethylene. Redo graft conduits were as follows: ipsilateral GSV in nine (40.9%), arm vein in six (27.3%), contralateral GSV in two (9.1%), "other veins" in two (9.1%), and homologous artery in three (13.6%). The same target artery was used in 81.8%, at the initial site in 54.5% and more distally in 27.3%. Redo revascularization for early failure was successful only once. Median follow-up after late redo was 23.7 months. Seven redo grafts performed after late pedal graft failure failed after a median of 115 days. The availability of adequate autologous conduit is the limiting factor for redo procedures. Lack of alternative outflow sites adds to the difficulty of target artery dissection. Redo pedal bypass surgery after early pedal bypass failure is associated with very poor patency and limb salvage. Acceptable patency and extension of limb salvage can be achieved with redo procedures for late pedal bypass failure.     

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.     

Early results of infragenicular revascularization based solely on duplex arteriography

PURPOSE: Recent reports have both advocated and questioned the utility of duplex arteriography (DA) as the sole preoperative imaging modality for planning infragenicular revascularization. This study compares the outcome of patients with critical limb ischemia who underwent infragenicular vein grafts on the basis of DA alone versus conventional preoperative contrast arteriography (CA). METHODS: The study group is composed of 23 consecutive patients who underwent infragenicular vein bypass grafting solely on the basis of preoperative DA from 1998 to 1999. They were compared with 50 consecutive patients who underwent infragenicular vein bypass grafting after CA from 1996 to 1998. Peak systolic velocity and end-diastolic velocity of potential target arteries were recorded during DA studies. In situ saphenous vein grafts were used preferentially, and technical adequacy of all grafts was assessed with completion duplex or arteriography. RESULTS: DA and CA groups were comparable on the basis of age and risk factors. In one limb (4%), the target artery selected by DA was abandoned because of dense calcification. No other revision in target or inflow artery was required on the basis of intraoperative completion studies. At 1 year, primary graft patency (78% vs 70%, P =.72) and limb salvage (70% vs 81%, P =.21) were comparable between the two groups. In the DA group, mean preoperative target artery peak systolic velocity in patent versus failed grafts was 49 +/- 18 cm/s versus 31 +/- 9 cm/s (P =.04), whereas mean end-diastolic velocity was 22 +/- 7 cm/s versus 14 +/- 8 cm/s (P =.08). CONCLUSION: Infragenicular revascularization directed by DA alone provides early graft patency and limb salvage rates comparable to similar procedures that are based on CA. Preoperative DA target artery velocities may predict outcome and improve target selection. These initial results justify further clinical testing of DA as the primary imaging modality for planning infragenicular vein grafts.     

Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience.

Long vein bypass from the femoral artery to the level of the ankle may be performed with good initial success despite extreme bypass length and limited outflow tracts. However, the long-term performance of these bypasses remains to be defined. During the last 10 years we have performed single greater saphenous vein in situ bypass to the ankle level in 270 patients. There were 187 male and 83 female patients, and 61% of the patients were diabetic. The operative mortality rate was 3.7%. Cumulative bypass patency was 79% at 3 years and 73% at 5 years. In a similar manner, limb salvage was 93% at 3 years and 89% at 5 years. The patency rate was similar for various inflow arteries (common femoral, 88 cases; proximal superficial femoral, 135 cases; and deep femoral, 41 cases) and outflow tracts (dorsal pedal, 72 cases; anterior tibial, 59 cases; posterior tibial, 72 cases, and peroneal, 67 cases). Short bypasses, composite bypasses, free-vein grafts, and bypasses proximal to 10 cm above the ankle were excluded from this analysis. These data show that a long bypass to the ankle level for limb salvage is a durable procedure. The basic concept of bypassing all occlusive disease to the distal open artery in patients undergoing limb salvage should be an acceptable dictum. Excellent long-term patency and limb salvage rates are achievable by following this principle.     

Patency and limb salvage after infrainguinal bypass with severely compromised ("blind") outflow

HYPOTHESIS: Infrainguinal graft patency and limb salvage are adversely affected by severely compromised outflow. DESIGN: Retrospective review of all infrainguinal bypass procedures performed at a single institution during a 5-year period. SETTING: University teaching hospital. PATIENTS: Two hundred seventy-four patients underwent infrainguinal bypass for limb salvage (351 grafts in 307 limbs). INTERVENTIONS: All infrainguinal bypasses originated from a femoral artery. The distal anastomosis in 279 grafts was located in an artery with at least 1 patent outflow vessel with anatomically normal end-artery runoff (Society for Vascular Surgery/International Society for Cardiovascular Surgery ad hoc committee runoff score, 1-9). The distal anastomosis of 72 grafts was located in an artery with only collateral outflow ("blind bypass"; runoff score, 10). MAIN OUTCOME MEASURES: Perioperative morbidity and mortality, primary-assisted and secondary graft patency, limb salvage, and survival. RESULTS: All data are presented as mean +/- SEM. Patients undergoing blind bypass were older (age, 70 +/- 2 vs. 66 +/- 1 years; P <.05) and had a higher incidence of hypertension (90% vs 70%; P <.05) and end-stage renal disease (24% vs. 13%; P <.05). Comparing patients undergoing blind bypass to bypass with at least 1 patent outflow vessel, there were no differences in the use of nonautogenous conduits (50% vs 59%; P =.21) or postoperative warfarin (30% vs 32%; P =.69), or in perioperative mortality rates (2.7% vs 3.2%; P =.79). After a median follow-up of 13 months (range, 0-60 months), 2-year secondary graft patency for the entire group was 63% +/- 4%. The secondary patency rate of blind bypass grafts was no different from that of grafts with at least 1 patent outflow vessel (67% +/- 7% vs. 64% +/- 4%; P was not significant). However, the 2-year limb salvage rate in limbs with blind outflow was significantly worse than in limbs with at least 1 patent outflow vessel (67% +/- 7% vs. 76% +/- 3%; P =.04). CONCLUSION: Acceptable long-term patency rates can be achieved in infrainguinal bypass grafts with blind outflow, although blind outflow remains a marker for subsequent limb loss in the chronically ischemic leg.     

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.     

Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short-term observations

Limbs of diabetic patients with distal tibial disease are frequently considered unreconstructible; however, when studied with intraarterial digital subtraction angiography, the dorsal pedal artery is frequently found to be patent. We have reviewed our recent experience with 96 patients, 94% of whom had diabetes and had 97 bypasses placed to the dorsal pedal artery. All procedures were for limb salvage. Superimposed infection was present in 42.3%. In 92 instances where intraarterial digital subtraction angiography successfully visualized the dorsal pedal artery, 91 bypasses were placed. In 12 other cases where the dorsal pedal artery was not visualized by intraarterial digital subtraction angiography but audible with the continuous-wave Doppler, bypasses were completed successfully in six. All procedures were performed with vein. Inflow was taken from the femoral artery in 48, popliteal artery in 45, tibial artery in 2, and from a femoral tibial graft in 2. Perioperative mortality was 1.92%. Actuarial graft patency, limb salvage, and patient survival were 82%, 87%, and 80%, respectively at 18 months. We conclude that bypass grafting to the dorsal pedal artery can be reliably performed with acceptable short-term results. An attempt should always be made to visualize the foot vessels angiographically, especially in diabetic patients, so that this valuable option in arterial reconstruction will not be overlooked.     

Early results for below-knee bypasses using Distaflo

In patients who require lower extremity revascularization, prosthetic graft is a reasonable alternative in the absence of a suitable autologous vein conduit. However, prosthetic bypass grafts have limited patency, especially for infrageniculate reconstruction. Polytetrafluoroethylene grafts were geometrically modified at the distal end to increase their patency. The authors reviewed their experience with the Distaflo graft in patients who required lower extremity below-knee popliteal and tibial bypasses when no suitable autologous vein conduit was available. Chart review was conducted of the 57 patients who underwent 60 lower extremity bypasses over a 3-year period between June 2003 and April 2006. Twenty-four revascularizations were constructed to the tibial outflow sites, whereas the remaining grafts were placed to the below-knee (28) and above-knee (8) popliteal artery, respectively. Study endpoints were primary, assisted primary, secondary patency, and limb salvage at the time of follow-up. Distaflo bypass was performed at the infrageniculate level in 86.7% of cases (28 below-knee popliteal, 24 tibial). Mean follow-up time was 12 months (range, 0.5-37.5 months). At 1 year, primary, assisted primary, and secondary patencies and limb salvage rates for below-knee popliteal bypasses were 83.5%, 89.5%, 94.7%, and 94.4%, respectively. Primary, assisted primary, and secondary patencies and limb salvage rates for tibial bypasses were 44.4%, 44.4%, 63.2%, and 74.9%, respectively. Distaflo precuffed graft is a good alternative conduit for below-knee popliteal and tibial lower extremity reconstructions in the absence of an autologous vein and appears to have promising early patency and limb salvage rates even when used for tibial bypasses.     

Follow-up of infrainguinal graft thrombolysis: analysis of predictors of clinical success

HYPOTHESIS: Thrombolysis is an accepted technique to salvage a failed infrainguinal bypass graft. Careful case selection, including consideration of the native arterial runoff and the type and location of the graft, will portend a better clinical outcome and prolonged graft patency. DESIGN: Retrospective study of an inception cohort of 91 acutely thrombosed grafts. SETTING: Academic tertiary care center. PATIENTS: We analyzed 91 consecutive occluded grafts in 69 patients for secondary graft patency and clinical outcome. INTERVENTION: Regional transcatheter thrombolysis. MAIN OUTCOME MEASURES: Technical success, secondary graft patency, and the need for major limb amputation. RESULTS: Immediate technical success resulting in restoration of flow was achieved in 80 (88%) of 91 cases. Angioplasty or additional surgical intervention (eg, patch, interposition graft, or jump graft to a more distal site) was performed in 44 subjects (64%). Longer duration of secondary patency was associated with synthetic vs vein grafts (P =.03), popliteal vs distal (tibial/pedal) insertion of the anastomosis (P =.008), and intact native arterial outflow (P =.003). Twenty-three cases required major limb amputation in the follow-up period, but 17 (74%) of these had reocclusion within 30 days of thrombolysis. Only 43 grafts (47%) were found to be patent at 1-year follow-up. CONCLUSIONS: In carefully selected cases, thrombolytic therapy is an effective means to restore limb viability in patients with occluded infrainguinal grafts. Long-term patency rates, although similar to those of surgical series, remain poor.     

Composite sequential grafts for femorocrural bypass reconstruction: experience with a modified technique

BACKGROUND: To evaluate the efficacy of a modification of the composite sequential femorocrural bypass graft that we adopted in 1985, a retrospective case-note study was undertaken. The grafts combined a prosthetic femoropopliteal section with a popliteal to crural section with autologous vein, linked via a common intermediate anastomosis sited on the above-knee popliteal artery. PATIENTS AND METHODS: Between 1985 and 2000, 68 grafts of this type were constructed in 65 patients with critical ischemia of the lower limb and insufficient autologous vein for construction of an all venous bypass. Reasons for insufficient long saphenous vein included previous lower limb bypass in 33 cases, phlebitis in 16 cases, venous hypoplasia in eight cases, and previous varicose vein surgery in seven cases. Distal anastomoses were carried out to the peroneal artery in 26 cases, the anterior tibial artery in 17 cases, the posterior tibial artery in 17 cases, and the pedal arteries in eight cases. Sources of vein included the long saphenous vein in 26 cases, the arm vein in 38 cases, and the short saphenous vein in two cases. In 22 limbs (32%), angiography had shown an occluded segment of above-knee popliteal artery, and in these cases, local popliteal disobliteration was performed to receive the composite anastomosis and to provide additional outflow. RESULTS: The 2-year cumulative primary patency, secondary patency, and limb salvage rates were 68%, 73%, and 75%, respectively. Localized popliteal disobliteration did not compromise graft patency (P =.07, with log-rank test). CONCLUSION: In the absence of sufficient autologous vein, patients needing bypass to crural arteries can be offered reconstruction with composite sequential grafting with satisfactory results. Furthermore, an occluded above-knee popliteal segment is not a contraindication for composite sequential bypass reconstruction.     

Limb loss with patent infra-inguinal bypasses

To determine systemic and local risk factors that contribute to limb loss despite a patent infra-inguinal bypass graft and how to prevent it, we reviewed 987 patients who underwent infra-inguinal bypasses at our institution. Seventy-five (7.6%) patent grafts failed to achieve a healed foot despite exhaustive attempts to do so and these patients underwent major amputation either above the knee (AKA) or below the knee (BKA). In 525 femoro-popliteal bypasses, there were 38 major amputations (29 BKA; 9 AKA) with a patent graft; in 462 femoro-distal bypasses, there were 37 amputations (22 BKA; 15 AKA) with a patent graft. The remaining 912 patients with limb salvage as well as all the patients with limb loss were evaluated with regard to systemic risk factors, quality of the run-off from the popliteal artery, continuity of the tibial artery into the arch as demonstrated on arteriography, the haemodynamic improvement obtained postoperatively, and the presence and extent of necrosis in the foot. The presence of diabetes, extensive pedal necrosis and advanced infection predispose to limb loss despite a patent lower extremity bypass graft. Patients who lost their limbs despite a functioning bypass to an isolated popliteal segment had significantly less pronounced haemodynamic improvement postoperatively. An early graft extension to a reconstituted tibial or peroneal artery or a direct bypass to a distal tibial or peroneal artery may reduce the incidence of limb loss in this setting. When a patent bypass to an isolated tibial or peroneal artery segment failed to relieve foot ischaemia, limb salvage was achieved by a distal extension to plantar arteries.     

Comparative analysis of autogenous infrainguinal bypass grafts in African Americans and Caucasians: the association of race with graft function and limb salvage

OBJECTIVE: African Americans (AAs) are at risk for developing diabetes mellitus and atherosclerosis. Whether race influences the results of infrainguinal arterial reconstruction is unclear. The purpose of this study was to compare the results of autogenous infrainguinal bypasses in AAs and Caucasians to determine the association of race with graft function and limb salvage. METHODS: This was a retrospective, comparative cohort study of AA and Caucasian patients who had undergone autogenous infrainguinal bypass surgery. Only single-limb bypasses in each patient cohort were considered in this analysis. In patients who had undergone bilateral lower limb bypasses, the first limb bypass was chosen as the index bypass procedure. RESULTS: From January 1985 to December 2003, 1459 autogenous infrainguinal bypasses were performed in 1459 patients for lower limb ischemia. Within this group, 89 AA patients/vein grafts formed the study cohort. The control group comprised 1370 Caucasian patients/vein grafts. Compared with the Caucasian cohort, AA patients were significantly younger (median age, 65 vs 70 years, respectively; P = .001) and predominantly female (57% vs 41%, respectively; P = .002). AA patients also had a higher prevalence of diabetes mellitus, hypertension, cerebrovascular disease, congestive heart failure, and dialysis-dependent renal failure. More AA than Caucasian patients presented with gangrene (34% vs 16%, respectively; P = .001), and more underwent bypass surgery for limb salvage indications (91% vs 81%, respectively; P = .01). The venous conduit used was predominantly the greater saphenous vein (AA, 83%; Caucasian, 85%), and the site of distal anastomosis was at the tibial/pedal level in 67% of AA and 61% of Caucasian patients. Overall morbidity (AA, 28%; Caucasian, 23%) and 30-day mortality (AA, 3%; Caucasian, 3%) were similar. Thirty-day graft failure was significantly greater in AAs than Caucasians (12% vs 5%, respectively; P = .003). The overall 5-year primary graft patency (+/-SE) was significantly worse in AA patients (AA, 52% +/- 6%; Caucasian, 67% +/- 2%; P = .009). The 5-year limb salvage rate (+/-SE) was also significantly worse in AA patients (AA, 81% +/- 5%; Caucasian, 90% +/- 1%; P = .04). With the Cox proportional hazard model, significant risk factors associated with primary graft failure were AA race, age younger than 65 years, female sex, secondary reconstructions, tibial bypasses, and critical limb ischemia. Significant risk factors associated with limb loss were age younger than 65 years, female sex, absence of coronary disease, presence of critical limb ischemia, and secondary reconstructions. CONCLUSIONS: Autogenous infrainguinal bypass surgery in AAs is associated with poorer primary graft patency and limb salvage rates compared with those of Caucasians. This may partially account for the higher rate of limb loss in AA patients with peripheral arterial occlusive disease.     

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.     

Dorsalis pedis arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes mellitus

Purpose:Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability.Methods:We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage.Results:Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 11 of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, onreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven erioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts.Conclusions:Dorsalis pedis arterial bypass is an effective limb salvage procedure with long-term durability comparable to distal vein grafts placed into more proximal arteries. (J VASC SURG 1995;21:375-84.)     

The relative importance of graft surveillance and warfarin therapy in infrainguinal prosthetic bypass failure

BACKGROUND: We sought to describe modes of failure and associated limb loss after infrainguinal polytetrafluoroethylene bypass grafting in patients lacking a saphenous venous conduit and to define specific clinical or hemodynamic factors prognostic for bypass failure. METHODS: We identified 121 patients (mean age, 67 years; 90 men and 31 women) with determinable outcomes (minimum follow-up, 2 months; mean, 17 months) after 130 prosthetic infrainguinal bypasses between 1997 and 2005. Ischemic presentation was rest pain in 52%, tissue loss in 34%, and disabling claudication and/or popliteal aneurysm in 14%, with 24% of patients requiring a redo bypass. Distal targets were the above-knee (n = 44), distal popliteal (n = 27), or tibial/pedal (n = 59) arteries. Sixty-six (77%) of the below-knee (BK) target (distal popliteal or tibial) bypasses had distal anastomotic adjuncts (vein cuff or patch). Duplex graft surveillance was performed at 1, 4, and 7 months after surgery and twice yearly thereafter, with recording of midgraft velocities and imaging encompassing inflow and outflow vessels. Arteriography and open/endovascular intervention was performed for stenoses identified by duplex scanning (peak systolic velocity >300 cm/s; velocity ratio >3.5). An attempt was made to salvage occluded grafts by using catheter-directed thrombolysis or open techniques. Eighty-six patients (74% of BK bypasses) were placed on chronic warfarin therapy with a target international normalized ratio range between 2 and 3. Prognostic factors were identified by using univariate statistics and multivariate logistic regression analysis. RESULTS: Three-year primary, assisted, and secondary patency rates were 39%, 43%, and 59%, respectively, for all bypasses, with no difference noted between above-knee and BK grafts (P = .5). At 3 years, freedom from limb loss was 75%, and patient survival was only 70%, with no adverse effect on survival imparted by amputation. Sixty-nine total adverse events occurred as a result of thrombotic occlusion (n = 51), duplex scan-detected stenosis (n = 13), or graft infection (n = 5). Forty-nine percent of all initial graft occlusions eventually led to amputation. Twenty-three grafts (27% of 86 patients) in patients maintained on chronic warfarin were subtherapeutic at the time of occlusion. Use of a distal anastomotic adjunct with BK bypasses reduced graft thrombosis (35% with vs 60% without) but did not impart a significant patency advantage (P = .07). Multivariate analysis revealed low graft flow (midgraft velocity < or =45 cm/s; odds ratio [OR], 6.1; 95% confidence interval [CI], 1.9-19.2), use of warfarin (OR, 8.4; 95% CI, 2.1-34.5), and therapeutic warfarin (OR, 24.6; 95% CI, 5.7-106) to be independently predictive for bypass patency. Graft patency was maintained in 89% of grafts remaining therapeutic on warfarin compared with only 55% of subtherapeutic or nonanticoagulated grafts (P < .001). Low-flow grafts (n = 61) occluded more frequently than higher-flow grafts (46% vs 13%; P < .001). Therapeutic warfarin augmented the patency of low-flow (P < .001) but not high-flow (P = .15) grafts. CONCLUSIONS: Low graft flow was a more common mode of prosthetic bypass failure than development of duplex scan-detected stenotic lesions during follow-up. Early duplex scanning may be more important for characterizing midgraft velocity and related thrombotic potential and selecting patients for chronic anticoagulation. Maintenance of therapeutic warfarin is paramount in optimizing prosthetic bypass patency and limb preservation.     

Pedal Bypass for Limb Salvage: Impact of Diabetes on Long-Term Outcome

Use of pedal bypass can salvage limbs of patients with critical ischemia. The aim of this study was to evaluate the results of surgical revascularization of pedal arteries in diabetic patients and to assess the impact of diabetes on long-term outcome. We performed a retrospective analysis of all consecutive pedal bypasses done between January 1, 1987 and December 31, 1997. Demographic data, surgical indications, operative variables, and postoperative results including graft patency and limb salvage were compared between diabetic and nondiabetic patients. The results of this comparison showed that pedal bypass can safely and effectively relieve critical ischemia in diabetic patients. Diabetics have less early graft thrombosis and superior long-term graft patency. Despite higher incidence of renal insufficiency or failure and more tissue loss, diabetics can achieve similar excellent limb salvage rates. This outcome justifies aggressive revascularization of pedal arteries in diabetic as well as nondiabetic patients with critical limb ischemia.     

The benefits of secondary interventions in patients with failing or failed pedal bypass grafts.

BACKGROUND: Autogenous bypass grafts to pedal arteries have successfully salvaged limbs and restored function in patients with critical ischemia. The benefits of secondary interventions to save failing or already failed grafts remains uncertain. METHODS: A retrospective analysis was made of consecutive pedal bypasses performed between 1987 and 1998. Patency and limb salvage by life-table analysis and variables affecting outcome were compared with the log-rank test. RESULTS: Two hundred thirteen patients, 144 males, 69 females (mean age 68 years, range 30 to 91) underwent pedal bypass grafting in 228 limbs using autogenous vein grafts (nonreversed saphenous vein, n = 190; reversed, n = 15; composite, n = 23). One-hundred fifty-seven patients were diabetic, 34 had renal insufficiency (serum creatinine >2.0), and 14 were on dialysis. Gangrene or ulceration were present in 224 patients, rest pain in 24. Cumulative primary and secondary patency rates were 57% and 67% at 5 years. Limb salvage was 78% at 5 years. Secondary interventions in 46 patients included patch angioplasty/surgical revision (n = 28), thrombectomy (n = 15), thrombolysis (n = 11), and balloon angioplasty (n = 6). Patency in 19 of 26 (73%) failed grafts and in 19 of 20 (95%) failing grafts could be restored initially. Cumulative 2-year patency and limb salvage rates following reinterventions were 36% and 58%, respectively. Patency rates and limb salvage for failed grafts (7%, 44%) were significantly worse than those for failing grafts (81%, 77%; P <0.0001, P <0.05, respectively). All patients with renal insufficiency who underwent reinterventions for failed or failing grafts required major amputation within 1 year (P <0.0001 versus those without renal insufficiency). CONCLUSION: Autogenous pedal bypass grafts are durable operations with excellent long-term patency and limb salvage rates. Revision of failing grafts has been effective using both endovascular and surgical techniques. Failed grafts have poor long-term patency and moderate limb salvage rates, and our data do not justify secondary procedures to attempt to save failed grafts in patients with renal insufficiency.     

Pedal or peroneal bypass: Which is better when both are patent?

Purpose: We compared autogenous vein pedal and peroneal bypasses, focusing on extremities that could have a bypass to either artery. Methods: From 1985 to 1993 we performed a total of 175 pedal and 77 peroneal autogenous vein bypasses for rest pain ( n = 75, 30%) and tissue loss ( n = 177, 70%). One hundred ninety-six (78%) in situ saphenous vein and 56 (22%) reversed or composite vein bypasses were performed. One hundred fifty-two of these 252 bypasses were performed in extremities with both the pedal and peroneal arteries patent by arteriography. The vascular surgeon chose to perform 99 pedal and 53 peroneal vein bypasses in these 152 extremities. Results: The angiogram score of the outflow arteries were similar for pedal and peroneal bypasses with the Society for Vascular Surgery and the International Society for Cardiovascular Surgery and modified scoring systems. At 2 years the primary and secondary patency rates for pedal bypasses (70% and 77%) were not significantly different compared with those for peroneal bypasses (60% and 72%). Limb salvage rates at 2 years were similar for pedal and peroneal bypasses for all patients (74% and 73%), patients with both pedal and peroneal arteries patent (83% and 72%), diabetics (76% and 66%), and patients with tissue necrosis (77% and 71%). Conclusions: Pedal and peroneal artery bypasses with equivalent angiogram scores have similar long-term graft patency and limb salvage. The choice between pedal or peroneal artery bypass should be based on the quality of vein and the surgeon's preference. (J VASC SURG 1994;20:347-56.)