Do results justify an aggressive strategy targeting the pedal arteries for limb salvage?.
We initiated a strategy to bypass all of the significant popliteal and tibial disease in the setting of limb-threatening ischemia beginning in September 1986. Of 194 infrapopliteal bypasses performed for limb salvage during the ensuing 6 years, 111 (57%) autogenous vein bypasses were performed to the pedal vessels at or distal to the ankle. By life table analysis, primary graft patency at 60 months for pedal bypasses was 57%, with salvage of failed grafts resulting in secondary patency of 61%. Limb salvage was 64% at 60 months. Of 33 graft thromboses, 24 (73%) resulted in eventual limb loss. Five limbs were amputated due to wound complications or progressive forefoot sepsis despite patent pedal grafts. More bypasses were performed to the dorsalis pedis than the posterior tibial at the ankle (78 vs 33), but patency and limb salvage were similar. Bypasses to the pedal arteries resulted in superior limb salvage compared with peroneal bypass when forefoot tissue necrosis was present (63 vs 33% at 36 months, P = 0.048). Pedal grafts had comparable overall patency (57 vs 64%) and limb salvage (64 vs 75%) to more proximal tibial bypasses. Pedal bypass provides acceptable long-term outcomes for both patency and limb salvage. When forefoot ischemic tissue loss is present, pedal bypass, when feasible, appears preferable to peroneal bypass.
Robison
J G
JG
Medical University of South Carolina, Ralph A. Johnson VA Medical Center, Charleston 29425, USA.
Cross
M A
MA
Brothers
T E
TE
Elliott
B M
BM
D003920:Diabetes Mellitus / Q000601:surgery; D005260:Female; D005734:Gangrene / Q000601:surgery*; D006801:Humans; D007511:Ischemia / Q000601:surgery*; D007866:Leg / Q000098:blood supply* / Q000601:surgery; D015993:Life Tables; D008297:Male; D012501:Saphenous Vein / Q000601:surgery; D016019:Survival Analysis; D014656:Vascular Surgical Procedures / Q000379:methods