Preservation of the ischemic leg by distal vascular bypass

"Femoro-distal bypass--a worthwhile procedure?"

Infrapopliteal vascular reconstruction was undertaken in 63 patients with limb threatening ischaemia. Graft materials used were reversed autogenous saphenous vein in 33 patients, umbilical vein in 23 patients, composites of saphenous and umbilical vein in six patients, and a Solcograft in one patient. At the end of the first month 13 grafts were non-functioning, and eight of these patients had an amputation performed. Cumulative 3-year limb salvage and patency rates were 69% and 35%, respectively. Cumulative patency rates of saphenous and umbilical vein grafts were equal, and neither the indication for operation nor the preoperative ankle-arm pressure index correlated to graft failure. In total, twenty-two major amputations were performed, 16 below or through the knee, and six above-knee. The conclusion is that vascular reconstructive surgery for limb threatening distal disease is a valuable procedure.

Reversed vein bypass to infrapopliteal arteries. Modern results are superior to or equivalent to in-situ bypass for patency and for vein utilization

In recent years many reports have attributed improved patency and improved vein utilization with lower extremity arterial bypass to infrapopliteal arteries to the use of the in-situ vein graft technique (ISVB). This report describes 110 reversed vein bypasses (RVB) to infrapopliteal arteries performed from 1980-1986. Thirty-three per cent of these patients did not have an intact ipsilateral greater saphenous vein. One hundred per cent of patients had autogenous RVB performed using a variety of techniques, including vein splicing, use of arm veins, lesser saphenous veins, branch veins, and use of graft origins distal to the common femoral artery. The life table patency figures for these grafts are 90%, 85%, and 85% at 1 year, 3 years, and 5 years, respectively. The life table limb salvage at 5 years is 93%. These figures for patency, vein utilization, and limb salvage for modern RVB to infrapopliteal arteries are clearly equal to or superior to any reported figures for ISVB. Results for RVB are greatly improved when compared with historic controls, as are results for ISVB. There is no evidence to date demonstrating superiority of one technique versus another.

In situ saphenous vein bypass grafting. Experience in 34 extremities over a 2 year period

Over a 2 year period, 34 limbs were revascularized in 33 patients. The in situ saphenous vein technique was used. Improved instrumentation and patency rates have encouraged the use of this method. Eighteen patients were insulin-dependent diabetics. The indication for operation was limb salvage in 25 limbs (73 percent). No vein was considered too small to use. The origin of 25 of the grafts were femoral and 9, popliteal. The termination of 15 of the grafts were popliteal, 11 tibial or peroneal, and 8 pedal. Of 12 limbs considered to be the most difficult to treat due to diabetes and accompanying poor runoff, 4 had a patent pedal arch. Initial graft patency was achieved in 94 percent of the limbs. Overall graft patency was 73 percent; femoropopliteal patency was 86 percent; and combined femoral, tibial, peroneal, and pedal patency was 64 percent. Learning the in situ bypass technique is tedious. The low thrombogenicity of the graft provides a temptation to extend operative indications. Use of the saphenous vein in situ can result in superior revascularization of the leg.

Femoropopliteal tibial bypass: what price failure?

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.

[The value of intraoperative arteriography in detecting complications of vascular surgery in the femoro-popliteal and crural region (author's transl)]

The intraoperative angiography was employed in 307 vascular reconstructive procedures (thrombendarterectomies (TEA) n = 107 = 34.8%; Veinbypass (VBP) n = 145 = 47.2%; fabric grafts (KBP) n = 44 = 14.4%) within the femoro-popliteal and crural region. 11.7% unsuspected technical errors were detected (TEA 18.6%, VBP 8.2%; KBP:6.8%) by angiography and successfully revised prior to wound closure. Errors were most common after thrombendarterectomies followed by VBP and KBP. Revisions after immediate failures were performed successfully in 7.4% (TEA : 8.4%, VBP: 5.5%, KBP: 6.8%). Lesions on X-ray of questionable significance were accepted in 6.8%, and followed by 4 immediate occlusions (1.7%). In 3.6% of the angiogramms the film was not satisfactorily exposed from the technical point of view. We think intraoperative angiography is a valuable adjunct in peripheral vascular surgery helping to detect and correct technical errors.

A new look at peripheral vascular disease in blacks: a two-year update

A comprehensive overview of 66 patients-the majority of whom were black-undergoing distal lower extremity revascularization for severe atherosclerotic ischemia with impending limb loss is presented. Twenty-five patients are presently two-years postoperative, 19 are one-year post revascularization, and 22 are new additions having undergone revascularization within the last year.Patients in the study group are presented according to race, sex, and age. Their histories and pre-operative clinical conditions, along with angiographic and operative findings lead to the identification of a previously undescribed atherosclerotic phenomenon present among blacks. The impact of an aggressive program for limb salvage is reported and the prospect of avoiding needless limb loss is discussed.

Infrapopliteal arterial reconstruction in the severely ischemic lower extremity. A comparison of long-term results of peroneal and tibial bypasses

The feasibility of limb salvage with bypasses to the infrapopliteal arterial tree has been established. In this review, our experience with bypasses to the peroneal artery is compared with that to the tibial arteries. Autogenous saphenous veins were employed in 164 limb salvage arterial revascularizations because of gangrene, ischemic ulceration, or rest pain. These were retrospectively analyzed by the life-table method. Femorotibial (137) or femoroperoneal (27) bypasses were performed on the basis of adequate preoperative arteriograms demonstrating the distal arterial tree, but with no popliteal runoff. Overall operative mortality was 6.1%. Initial limb salvage was 71.2 +/- 3.9% following femorotibial bypass and 51.9 +/- 9.6% after femoroperoneal bypass. Five and seven year cumulative limb salvage rates for femorotibial bypass were 48.5 +/5.2% and 43.4 +/- 6.7%; those for femoroperoneal were equivalent at 38.2 +/- 9.9%. Since long-term limb salvage can be realized in a large number of patients by revascularization of the distal arterial tree, primary amputation is seldom indicated. Operative approach to the ischemic limb must be based on a thorough preoperative arteriogram which demonstrates contrast within vessels down to the distal foot. This is almost always seen and arterial reconstruction is usually feasible. Therefore, limb salvage should be attempted in lieu of primary amputation whether tibial or peroneal arteries are visualized on preoperative arteriogram.

Vein bypass to the tibial, peroneal and dorsalis pedis arteries for limb ischaemia

Fifty-nine autogenous vein bypass grafts were performed to the distal leg arteries in 57 patients for limb salvage over a 10 year period.Analysis of results by the Life Table showed a cumulative patency of 74% at 1 month and 59% patency at 6 years. Failure of the vein graft in the early post-operative period resulted in amputation, and in almost 50% of cases, at an aboveknee level. Of 18 patients whose grafts thrombosed, 16 required major amputation, and infection in another 6 patients with patent grafts resulted in limb loss. With these exceptions, all the patients with patent grafts had viable and functional limbs. Of 37 diabetic patients subjected to operation, 17 lost their limbs during follow-up. There was no significant difference in patency of grafts inserted proximally or distally into the tibial vessels. The hospital mortality was 8% and one-fourth of patients subjected to operation died of causes related to atherosclerosis during follow-up.Reduction of the early post-operative failure rate by careful patient selection and meticulous operative technique makes arterial bypass operations to the distal tibial vessels beneficial to many patients who are otherwise doomed to amputation.