Aggressive arterial reconstruction for critical lower limb ischaemia

Abstract

A consecutive series of 315 patients underwent arterial reconstruction for 329 critically ischaemic lower limbs over a 5-year period. Patients were not excluded from limb salvage surgery on the basis of poor run-off on preoperative angiography. Femorocrural bypass to a single calf vessel was required in 239 limbs (73 per cent); the 30-day cumulative mortality rate was 7 per cent, rising to 41 per cent at 5 years. Cumulative graft patency at 30 days, 1 year, 2 years and 5 years was 96, 85, 84 and 82 per cent respectively and was independent of the level of reconstruction. In situ long saphenous vein was the conduit of choice for distal bypass but, when this was absent, satisfactory results were obtained with arm vein or composite vein grafts. Acceptable results can be obtained for reconstructive surgery without preoperative angiographic selection of patients. An aggressive approach to limb salvage is therefore justified.

Sequential compression biomechanical device in patients with critical limb ischemia and nonreconstructible peripheral vascular disease

“…The 5-year mortality rate for CLI patients is 70%, and most of these deaths are cardiovascularly related. [19][20][21][22] It is challenging to portray the natural history of CLI; therefore, management strategies must be mastered, and the cardiovascular burden should be acknowledged and managed aggressively.…”

Critical Limb Ischemia: Definition and Natural History

“…The rate of primary amputation ranges from 10% to 40%, and was performed only when no graftable distal vessels were present, or in neurologically impaired or hopelessly nonambulatory patients [2]. Differently, in some highly specialized and "aggressive" centres revasculation was attempted in about 90% of the patients with CLI [30,31]. For the subgroup of patients non candidates for arterial reopening procedures and those in whom these procedures have failed, results at 6 months show that approximately 40% will lose their leg [32,33].…”

Results of bypasses to the anterior tibial artery through the interosseous membrane

“…Because we were dissatisfied with externally tunneled bypasses to the anterior tibial artery, in terms of skin complications, and empirically thought that the anatomic route would enable the conduit to assume a more harmonious adaptation to the knee joint when crossing through the interosseous membrane, we began to tunnel grafts directed to the anterior tibial artery in an anatomic fashion. Overall patency of this series is 50% at 3 years, with a limb salvage rate of 70% for the same interval: this is within the overall standard results of distal revascularization [1,2,4,5,10,11].…”

“…Aggressive revascularization of lower limbs in critical ischemia by means of bypasses to the tibial arteries has become an accepted method to achieve good salvage rates in such threatened limbs [1,2]. Revascularization of tibial vessels can by performed with different techniques.…”