R. Robert Tyson

Long-term results of femoroinfrapopliteal bypass in diabetic patients with severe ischemia of the lower extremity☆

In patients with severe lower extremity ischemia (ischemic necrosis or pain at rest associated with physical findings of peripheral arterial insufficiency), diabetes mellitus should not deter thorough arteriography and consideration of arterial reconstruction. Infrapopliteal bypass can produce prolonged limb salvage in diabetic patients in lieu of primary amputation.

Comparison of Long-term Results of 364 Femoropopliteal of Femorotibial Bypasses for Revascularization of Severely Ischemic Lower Extermities

Successful revascularization of the severely ischemic lower extremity can be achieved by femorotibial as well as femoropopliteal bypass. The incidence of delayed graft occlusion after salvage of the severely ischemic lower extremity is low in patients with femorotibial or femoropopliteal bypass. Femorotibial bypass was performed in over one-third of patients undergoing bypass. Tibial bypasses resulted in effective prolonged revascularization of the severely ischemic lower extremity. An aggressive diagnostic and therapeutic approach to revascularization of the severely ischemic lower extremity can result in prolonged limb salvage by tibial or popliteal bypasses in lieu of primary amputation.

Redo surgery for graft failure

One of the most vexing problems [1,2] confronting the vascular surgeon is whether or not to reoperate because of graft failure. Graft failures that occur early in the immediate postoperative period often present as limb-threatening emergencies, and a decision must be made whether or not to reoperate. If reoperation is opted for, the question always arises: What can be done to prevent a failure the second time? Although late graft failures may also present as emergencies, they do not carry the threat of a second major operative procedure within a short period of time nor do they carry the implication that there is a technical error or an insoluble problem. The risk of reoperation is considerable, particularly because of the age range of’the patients and the concomitant disease present in so many of the patients who needed reconstructive vascular surgery to begin with. The problem becomes even more acute if surgery was originally done for claudication alone and now, with the sudden occlusion, the limb is threatened. Redo surgery involves consideration of several important factors. The first is the cause of the failure. It is apparent that unless the cause of the failure can be identified and then corrected or eliminated, the reoperative procedure will be failure. As with most situations in medicine, careful attention to detail at the original operation is the best method of preventing failure. It is also important that the patient be given the rather simple instructions to prevent graft occlusion by careful attention to some minimal positional rules. Lastly, attention to the factors of reoperation, the pitfalls, and some of the general technics that can be used is warranted.

Femoroperoneal bypass: evaluation of potential for revascularization of the severely ischemic lower extremity.

In 79 patients in whom distal small vessel bypass with autogenous vein was used for revascularization because of gangrene, gangrenous ulceration or rest pain, 14 had femoroperoneal bypasses. Femorotibial or femoroperoneal bypasses were performed in those patients in whom no popliteal runoff was present on pre-operative arteriogram. Femoroperoneal bypass was performed in preference to primary amputation in each case. Nine of 14 (64.3%) of femoroperoneal bypasses were functional whereas 57 of 79 (72.2%) of total distal bypasses to small vessels were functional. Salvage of severely ischemic lower extremities was achieved in 5 of 14 (35.7%) patients after femoroperoneal bypass and in 46 of 65 (70.8%) patients after bypass to anterior tibial or posterior tibial arteries. Graft patency without limb salvage occurred in 4 of 9 (44.4%) patients with patent femoroperoneal bypasses and in only 2 of 48 (4.2%) of patients with femorotibial bypass. Although limb salvage rate is considerably less with femoroperoneal than femorotibial or femoropopliteal bypass, attempted limb revascularization by peroneal bypasses is preferable to primary amputation in patients with rest pain, gangrenous ulceration or gangrene.

Femorotibial bypass in the diabetic patient for salvage of the ischemic lower extremity.

Severe ischemia of the lower extremity in diabetic patients without runoff in the popliteal artery should not deter an aggressive diagnostic and therapeutic approach. Femorotibial or femoroperoneal bypass can effect limb salvage and avoid primary amputation if distal small vessel patency can be demonstrated by arteriography.

Angiographic Criteria for Small-Vessel Bypass

Bypass surgery to small vessels below the knee is capable of salvaging, in useful condition, limbs which heretofore would have been amputated. Selection of patients requires angiograms of excellent quality down to and including the foot with sufficiently prolonged filming to answer the following: (a) Is there a patent vessel? (b) Is the angiographic internal diameter at least 1.2 mm? (c) Is there adequate run-off? Ultrasound is a useful adjuvant in programming exposures which must sometimes extend into the 30–50-second range. Cine definition is inadequate. Examples demonstrate these points and postoperative results.