Surgery of Infrapopliteal Occlusions

Abstract

With improving techniques for vascular surgery, successful treatment of increasingly distal arterial occlusions have become possible. Whereas the popliteal artery was once felt to be the distal limit for reconstructive surgical procedures, the surgical literature is now replete with examples of successful bypass grafts to arteries below the popliteal trifurcation. Refinements in techniques for suturing small blood vessels have resulted in high patency rates for anastomoses of vessels of one to two mm in diameter. Obviously, careful meticulous technique, small instruments, fine suture materials and magnification aids are essential to achieve these results. The application of these extended vascular grafting procedures has resulted in many examples of limb salvage in patients otherwise faced with amputation of their limbs.Concomitant with improvement in these direct arterial surgical techniques has been an improvement in rehabilitative methods, including improved physical therapy, improved prosthetic devices and, especially, the use of immediate postsurgical prostheses. These methods have allowed earlier and better ambulation of those patients who require amputation because of arterial occlusive disease.In view of the improved success in rehabilitation and due to the fact that many patients requiring distal arterial procedures for limb salvage are elderly and are poor surgical candidates, it is necessary to question whether it is worthwhile to attempt procedures involving anastomoses to arteries distal to the popliteal artery, rather than proceeding directly to amputation. It is recognized that the vascular surgeon is responsible for more than just the performance of an arterial revascularization procedure, but that his thrust must be toward rehabilitating the entire patient in the most expeditious manner. There is little argument that in the routine patient with ischemia due to superficial femoral artery occlusion that attempt at femoral popliteal bypass is preferable to immediate amputation. However, patients requiring infrapopliteal anastomoses are a different group; they are in general more elderly, have extensive and widespread arteriosclerosis and are frequently diabetic. Of the 33 patients at the Jewish Hospital of St. Louis undergoing infrapopliteal bypass procedures, the average age was 70.4 years, 66 percent had had either a previous myocardial infarction or a cerebrovascular accident and 70 percent were diabetic. Whether a prompt amputation in conjunction with early ambulation is preferable to the major operative procedure required to revascularize a limb with infrapopliteal occlusions is not so easily answered.In an attempt to clarify this problem, several questions must be considered.