Dorothy V. Freeman

Lower extremity arterial reconstruction in the very elderly: Successful outcome preserves not only the limb but also residential status and ambulatory function ☆ ☆☆ ★

PURPOSE The purpose of this study was to evaluate our results with lower extremity arterial reconstruction (LEAR) in patients 80 years of age or older and to assess its impact on ambulatory function and residential status. METHODS We performed a retrospective review of all patients 80 years of age or older undergoing LEAR at a single institution from January 1990 through December 1995. Preoperative information regarding residential status and ambulatory function was obtained from the hospital record and vascular registry. Telephone interviews with patients or next of kin were undertaken to provide information regarding postoperative residential status and ambulatory function. Residential status and level of ambulatory function were graded by a simple scoring system in which 1 indicates living independently, walking without assistance; 2 indicate living at home with family, walking with an ambulatory assistance device; 3 indicates an extended stay in a rehabilitation facility, using a wheelchair; and 4 indicates permanent nursing home, bedridden. Preoperative and postoperative scores for both residential status and ambulatory function were compared. Kaplan-Meier survival curves were generated for graft patency, limb salvage, and patient survival. RESULTS Two hundred ninety-nine lower extremity bypass operations were performed in 262 patients 80 years of age or older (45% men, mean age 83.6 years, range 80 to 96 years). Sixty-seven percent of the patients had diabetes mellitus. Limb salvage was the indication for operation in 96%. The preoperative mean residential status and ambulatory function scores were 1.79+/-0.65 and 1.55+/-0.66, respectively. The perioperative mortality rate at 30 days was 2.3%. The median length of hospital stay decreased from 16 days in 1990 to 8 days in 1995 (range 4 to 145 days). Eighty-seven percent of grafts were performed with the autologous vein. The 5-year primary, assisted primary, and secondary graft patency rates for all grafts were 72%, 80%, and 87%, respectively. The limb salvage rate at 5 years was 92%. The patient survival rate at 5 years was 44%. The postoperative residential status and ambulatory function scores were 1.95+/-0.80 and 1.70+/-0.66, respectively. Overall scores remained the same or improved in 88% and 78% of patients, respectively. CONCLUSION LEAR in octogenarians is safe, with graft patency and limb salvage rates comparable to those reported for younger patients. LEAR preserves the ability to ambulate and reside at home for most patients.

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.

Maximizing Foot Salvage by a Combined Approach to Foot Ischemia and Neuropathic Ulceration in Patients With Diabetes: A 5-year experience

OBJECTIVE The combination of peripheral neuropathy and arterial insufficiency in patients with diabetes frequently results in chronic non-healing foot ulcers. These patients often have a protracted course that commonly ends in limb amputation. RESEARCH DESIGN AND METHODS Since 1987, 39 diabetic patients presented with 42 neuropathic ulcerations beneath the lesser metatarsal heads, complicated by severe arterial insufficiency. A variety of vascular reconstructions were performed to improve circulation to the foot. After successful vascular reconstruction, 14 patients with deep ulcers underwent resection of the involved bone or joint through a plantar elliptical incision with excision of the ulcer and primary closure (33%). Five patients required a simultaneous panmetatarsal head resection (12%). For fifteen superficial ulcers, metatarsal osteotomy through a dorsal approach was performed (36%). Eight patients underwent a fifth metatarsal head resection through a dorsal approach (19%). RESULTS In follow-up of 2–64 months (mean 21.2 months), 35 extremities with patent bypass grafts achieved and maintained primary healing of their local foot procedure (83%). Two feet required subsequent revision but ultimately healed (5%). Three feet (7%) developed a new plantar ulceration adjacent to the original one. In two extremities, the foot remained healed in spite of thrombosis of their grafts (5%). One patient with a thrombosed graft required a below-knee amputation. One patient died before the foot healed with a patent bypass graft. Overall, 40 of 42 extremities (95%) ultimately healed over the course of the follow-up period. CONCLUSIONS We conclude that complex neuropathic ulcers in diabetic patients can be successfully treated by an aggressive surgical approach that removes infected bone and ulcers and corrects underlying structural abnormalities provided arterial insufficiency is corrected first.

Safety of vein bypass grafting to the dorsal pedal artery in diabetic patients with foot infections

The results of 56 vein bypasses to the dorsal pedal artery performed in 53 diabetic patients who were admitted with ischemic foot lesions complicated by infection were reviewed. All patients had one or more of the following: infected ulcers (73%), cellulitis (45%), osteomyelitis (29%), gangrene (20%), or abscess (2%). Organisms were cultured from 84% of patients (average 2.6, range 1 to 9 organisms per infection). Elevated temperature (greater than 37.7 degrees C) or leukocytosis (greater than 9.0 x 10(3)/ml) were seen in 13% and 50% of patients, respectively. All patients were treated with broad-spectrum antibiotics, local debridement, wound care, and bed rest. Operative debridement or open partial forefoot amputation were required to control sepsis in 11 patients (20%). Treatment of infection delayed revascularization by an average of 10.7 days. All patients underwent autogenous vein bypasses to the dorsal pedal artery. Two grafts failed within 30 days (3.6%), and one patient died (1.8%). Wound infections developed in seven patients (12.5). One wound infection resulted in graft disruption and patient death at 2 months. Average length of stay of the initial hospitalization was 29.8 days. Fifty-two patients were discharged with patent grafts and salvaged limbs; however, 31 subsequent foot procedures and 35 rehospitalizations were required to ultimately achieve foot healing. Actuarial graft patency and limb salvage were 92% and 98%, respectively at 36 months. Pedal bypass to the ischemic infected foot is efficacious and safe as long as infection is adequately controlled first. The complexity of these situations often requires multiple surgical procedures and extensive wound care, resulting in prolonged or multiple hospitalizations.

Anesthesia type does not influence early graft patency or limb salvage rates of lower extremity arterial bypass

PURPOSE The effect of anesthesia type on 30-day graft patency and limb salvage rates was evaluated in patients who underwent femoral to distal artery bypass. METHODS Of 423 patients randomly assigned to receive general, spinal, or epidural anesthetic, 76 did not meet protocol standards and 32 had inadequate anesthesia. A chart review of the remaining 315 patients was undertaken to obtain surgical information not recorded in the original study. All patients were monitored with radial and pulmonary artery catheters. After surgery, patients were in a monitored setting for 48 to 72 hours and had graft function assessments hourly during the first 24 hours and then every 8 hours until discharge. RESULTS Fifty-one patients were lost to follow-up (15 general, 22 spinal, 14 epidural). Baseline clinical characteristics were similar for the three groups except prior carotid artery surgery, which was more common in the spinal group. Indications for surgery were also similar except for a higher incidence of nonhealing ulcer in the epidural group. There were no differences among groups for 30-day graft patency with or without reoperation, 30-day graft occlusion, death, amputation, or length of hospital stay. CONCLUSION These results suggest that the type of anesthetic given for femoral to distal artery bypass does not significantly affect 30-day occlusion rate, limb salvage rate, or hospital length of stay.

Comparison of angioscopy and angiography for monitoring infrainguinal bypass vein grafts: Results of a prospective randomized trial

PURPOSE This study was designed to determine whether, in primary infrainguinal bypass grafts in which only saphenous vein is used as the graft conduit, routine monitoring with intraoperative angioscopy can improve early graft patency as compared with standard monitoring with intraoperative completion angiography; and to delineate the advantages and disadvantages of these two modalities and their respective roles for the routine monitoring of the infrainguinal bypass graft. METHODS A total of 293 patients undergoing primary saphenous vein infrainguinal bypass grafting were prospectively randomized and monitored with either completion angioscopy or completion angiography. Clinical parameters, indications for operation, graft anatomy, and configuration were evenly matched in both groups. Forty-three bypasses were excluded from the study after randomization, including 12 veins randomized to angiogram, deemed inferior, and prepared with angioscopy. RESULTS In the 250 bypass grafts (angioscopy 128, angiography 122) there were 39 interventions (conduit, 29; anastomosis, 8; distal artery, 2), 32 with angioscopy and 7 with angiography (p < 0.0001). Twelve (4.8%) of the 250 grafts failed in less than 30 days, four (3.1%) of 128 in the angioscopy group and eight (6.6%) of 122 in the angiography group (p = 0.11 by one-sided hypothesis test). CONCLUSION Although no statistical improvement in the proportions of failures in primary saphenous vein bypass grafts routinely monitored with completion angioscopy rather than the standard completion angiogram was demonstrated, the study delineates a trend that favors completion angioscopy for routine vein graft monitoring and demonstrates the advantages of angioscopy in preparing the optimal vein conduit.

Popliteal-to-distal bypass grafts for limb salvage in diabetics

Between January 1984 and August 1989, 117 diabetic patients with a palpable popliteal pulse but distal limb threatening ischaemia underwent 124 popliteal artery (or below) to distal bypass grafts. All grafts were intra-operatively monitored. The operative mortality was 0.8% and the 30 day primary patency 93%. Primary patencies at 1 and 3 years were 88.6 and 85.2%, respectively. The results of using the popliteal artery as the proximal graft inflow site in diabetes are comparable to other patient groups and to alternative more proximal inflow sites, but require a shorter length of vein graft with a shorter vein harvesting incision, avoid groin disection and result in a more peripheral operation.

Diabetes mellitus: A risk factor for carotid endarterectomy? ☆ ☆☆

PURPOSE Symptomatic cerebrovascular disease is more common in patients who have diabetes mellitus than in the nondiabetic population, even when matched for associated risk factors. Although the safety and efficacy of carotid endarterectomy has been established by NASCET and ACAS, several small studies have noted an increased rate of perioperative neurologic morbidity in patients with diabetes. METHODS Data for all patients who underwent carotid endarterectomy at a single institution from Jan. 1990 to Dec. 1995 were prospectively entered into a computerized vascular registry and form the basis of this report. RESULTS Of 732 carotid endarterectomy procedures performed, 284 (39%) were performed in patients who had diabetes mellitus. Patients with diabetes and without diabetes were matched for clinical presentation (diabetic patients, 45% asymptomatic; nondiabetic patients, 43%) and internal carotid artery percent stenosis (86.6% +/- 10.6% vs 86.4% +/- 10.6%). Patients with diabetes were younger at presentation than patients without (68.8 +/- 8.5 years vs 70.9 +/- 8.5 years; p < 0.005) and were more likely to have a history of coronary artery disease (53% vs 45%; p = 0.04). The mean total length of stay was 6.1 days for patients with diabetes and 4.8 days among patients without (p = 0.01). An adverse postoperative cardiac event (myocardial infarction, congestive heart failure, or arrhythmia) occurred in nine patients with diabetes (3.2%) and in five nondiabetic patients (1.1%; p < 0.05). By logistic regression analysis, however, diabetes was not an independent risk factor for a postoperative cardiac event (p = 0.28). There were 11 perioperative neurologic events (eight cerebrovascular accidents, three transient ischemic attacks) during the entire period (1.5%), of which six were among diabetic patients (2.1%) and five among nondiabetic patients (1.1%; p = NS). Of the eight cerebrovascular accidents, three occurred in diabetic patients (1.0%) and five in nondiabetic patients (1.1%; p = NS). The total operative mortality rate was 0.3% (diabetic patients, 1 of 284, 0.35%; nondiabetic, 1 of 447, 0.2%). CONCLUSIONS Patients with diabetes who undergo carotid endarterectomy are more likely to have coexisting cardiac disease, which may contribute to a higher incidence of postoperative cardiac morbidity. Diabetes mellitus alone, however, is not a risk factor for postoperative cardiac morbidity in patients who undergo carotid surgery. In addition, carotid endarterectomy may be safely performed in patients with diabetes with neurologic morbidity and mortality rates that are comparable with those of the nondiabetic population

Arigioscopy of Arm Vein Infrainguinal Bypass Grafts

Between January 1988 and December 1990, 56 patients underwent 66 arm vein infrainguinal bypass grafts for limb salvage. Thirty-nine grafts were intraoperatively monitored by the standard methods of continuous wave Doppler alone (30) and arteriography (9). Twenty-seven grafts were prepared and monitored by intraoperative angioscopy. No significant findings requiring intraoperative revision or correction were noted in the grafts monitored by the standard methods. However, in those grafts prepared and monitored by angioscopy, intraluminal abnormalities of the arm veins were detected and corrected in 20/27 (74%). None of the grafts prepared or monitored by angioscopy occluded within 30 days, whereas, in those grafts monitored by continuous wave Doppler and arteriography, 7/39 failed within 30 days, a primary patency rate of 32/39 (82%) (x2 with Yates correction, p=0.055). This study shows that angioscopic preparation and monitoring of arm vein bypass grafts allows the detection and correction of unsuspected intraluminal abnormalities, which appears to improve the early primary patency of arm vein infrainguinal bypass grafts.

Infrapopliteal bypasses to severely calcified, unclampable outflow arteries: Two-year results☆☆☆★★★

PURPOSE Although severe, circumferential calcification of distal outflow vessels is frequently encountered, its effect on bypass graft patency rates has not been well established. METHODS Using a computerized vascular registry database, we conducted a retrospective review of 1957 bypass grafts with distal anastomoses to infrapopliteal vessels performed at a single institution between 1990 and 1995. Of these cases, 101 procedures involved outflow arteries classified by the operating surgeon as severely calcified and unclampable (requiring intraluminal occluders for vascular control), whereas in 105 cases the outflow arteries had no calcification present at the distal anastomotic site. The remaining cases had varying intermediate degrees of calcification and were not analyzed. Indication for bypass procedure was limb-threatening ischemia in 90% of severe calcification cases and in 84% of cases without calcification. Atherosclerotic risk factors were similar except for the presence of diabetes (92% vs 74%, p < 0.001), creatinine level > 2.0 mg/dl (21% vs 8%, p < 0.01), and dialysis dependency (17% vs 3%, p < 0.001), all of which were more prevalent in the severe calcification group. Infrapopliteal distal anastomotic location and type of conduit ( > 90% autogenous vein) were comparable between groups. RESULTS Primary patency, secondary patency, and foot salvage rates at 24 months were 60%, 65%, and 77% for the severe calcification group and 74%, 82%, and 93% for the no calcification group, respectively. With secondary procedures comprising 26% of cases in each group, data from the 150 primary procedures were reanalyzed separately. In this primary procedure group, 24-month primary patency, secondary patency, and foot salvage rates were 66%, 69%, and 77% for the severe calcification group and 84%, 90%, and 96% for the no calcification group, respectively. Although patency and salvage rates were consistently lower for the severe calcification group in all analyses, these differences did not achieve significance by log-rank life-table analysis at 2-year follow-up. Perioperative 30-day mortality (0.99% severe calcification vs 0.95% no calcification) and 24-month survival rates (84% severe calcification vs 83% no calcification) were also similar between groups. CONCLUSION These data suggest that effective techniques exist to perform infrapopliteal bypasses to severely calcified, unclampable outflow arteries with results comparable with those obtained with clampable, uncalcified vessels. The finding of severe, circumferential calcification of outflow target arteries should not dissuade vascular surgeons from distal bypass for limb salvage indications.