Progress in Limb Saivage by Reconstructive Arterial Surgery Combined with New or Improved Adjunctive Procedures

Abstract

In the past nine years, 1196 patients whose lower extremity was threatened because of infrainguinal arteriosclerosis have been treated at Montefiore Hospital. In the last six years, limb salvage was attempted in 679 or 90% of 755 patients. Femoropopliteal (318), small vessel (204) and axillopopliteal (29) bypasses were used along with transluminal angioplasty (128) and aggressive local operations to obtain a healed foot. Immediate (one month) limb salvage was achieved in 583 or 86% of the 679 patients in whom revascularization was possible. The 30-day mortality rate was 3%. The cumulative life table (LT) survival rate of all the patients undergoing reconstructive arterial operations was 48% at five years. The cumulative LT limb salvage rate after all reconstructive arterial operations was 66% at five years. The cumulative LT patency rate of femoropopliteal bypasses was not influenced by angiographic outflow characteristics of the popliteal artery but was increased 15% by appropriate reoperations to 67% at five years. Cumulative LT patency and limb salvage rates of small vessel and axillopopliteal bypasses were more than 50% at two years. Of patients undergoing arterial reconstruction, 88% of those who died within five years did so without losing their limbs. Of all the patients in whom limb salvage was attempted, 68% lived more than one year with a viable, useable extremity, and 54% lived over two years with an intact limb. We believe this aggressive approach to limb salvage is justified, and can be undertaken with a low cost in mortality, knee loss and morbidity.

Selective Preservation of Infected Prosthetic Arterial Grafts Analysis of a 20-Year Experience with 120 Extracavitary-Infected Grafts

“…We believe that our low amputation rate primarily is because of the following three factors: 1) attempted complete graft preservation had been achieved successfully in approximately three quarters (32/45) of surviving patients; 2) patency of the underlying artery and important collaterals were maintained by leaving an oversewn prosthetic graft cuff on the artery when subtotal graft excision was necessary to treat occluded infected grafts; and 3) an aggressive approach to limb salvage was used by carrying out extra-anatomic bypass in clean fields throughout this 20-year period, when a secondary revascularization was required after infected graft excision or occlusion. 14,22 Complete graft preservation under certain conditions, even when the graft-artery anastomosis is involved in the infectious process, represents the most important new aspect of our management scheme. By preserving arterial supply to the threatened limb, successful graft preservation often obviates the need to perform complex sec-ondary bypasses.…”

Tibioperoneal (Outflow Lesion) Angioplasty Can Be Used as Primary Treatment in 235 Patients With Critical Limb Ischemia

“…Femoropopliteal arterial reconstruction for infrainguinal peripheral arterial occlusive disease has better immediate and long-term results in patients with claudication than in those with CLI, 14 and elective bypass surgery to the distal tibial vessels for intermittent claudication has had poor results. Thus, tibial artery bypass surgery to achieve revascularization distal to infrapopliteal obstructions has been reserved for selected CLI patients except in the presence of lifethreatening sepsis (until resolved), 15 flexion contractures or paralysis, 16 patients with serious comorbid medical conditions, or patients with markedly reduced life expectancy.…”

Revascularization of amputation candidate diabetic feet

“…Genel kanı, alt ekstremite baypaslarında proksimal anastomoz hattının ana femoral arter olarak seçilmesinin başarıyı artıracağı yönünde olsa da yüzeyel femoral arterin korunduğu durumlarda proksimal saha olarak seçilmesi greft boyunu kısaltarak oldukça başarılı sonuçların alınmasına neden olmaktadır. [4,5,16] Biz de çalışmamızda ana femoral artere ek olarak aterosklerozun etkilemediği olgularda sıklıkla yüzeyel femoral arter distali veya popliteal arteri proksimal anastomoz sahası olarak kullandık. Bu durum, hem çoğu diyabet ve ileri yaş nedeniyle kötü kalitede safen ven grefti olan hem de daha önce çeşitli nedenlerle safen ven grefti kullanılmış olan hastalarda greft uzunluğunu azaltmakta ve kısa segment kullanılması nedeniyle de greft açıklığına olumlu katkıda bulunmaktadır.…”

“…[2,3] İlk evrelerde ise aktif yaşam beklentisi yüksek olan hastalara distal revaskülarizasyon şansı verilebilmektedir. [4,5] İleri evre distal periferik arter hastalığı olup, anjiyografide düşük veya orta kalitede distal yatağı olan hastalarda medikal tedavinin sonuçları tatminkar değil-dir. [5][6][7] Bu amaçla çalışmamızda diabetes mellitus (DM) zemininde ileri evre distal yerleşimli periferik arter hastalığı olan, revaskülarize edilmesi için anjiyografik incelemelerinde lümen ve daha distalinde run-off görüntüsü olan ve kritik iskemi nedeniyle amputasyona doğru giden hastalarda ön veya arka tibial arter distal revaskülarizasyon ve medikal tedavinin klinik sonuçları karşılaştırılmıştır.…”