Changing Arterioselerotic Disease Patterns and Management Strategies in Lower-limb-Threatening Ischemia

Abstract

From January 1, 1974 to December 31, 1989, we treated 2829 patients with critical lower-extremity ischemia. In the last 5 years, 13% of patients had therapeutically significant stenoses or occlusions above and below the groin, while 35% had them at two or three levels below the inguinal ligament. Unobstructed arterial flow to the distal half of the thigh was present in 26% of patients, and 16% had unobstructed flow to the upper third of the leg with occlusions of all three leg arteries distal to this point and reconstitution of some patent named artery in the lower leg or foot. In the last 2 years, 99% of all patients with a threatened limb and without severe organic mental syndrome or midfoot gangrene were amenable to revascularization by percutaneous transluminal angioplasty (PTA), arterial bypass, or a combination of the two, although some distal arteries used for bypass insertion were heavily diseased or isolated segments without an intact plantar arch. Limb salvage was achieved and maintained in more than 90% of recent patient cohorts, with a mean procedural mortality rate of 3.3%. Recent strategies that contributed to these results include (1) distal origin short vein grafts from the below-knee popliteal or tibial arteries to an ankle or foot artery (291 cases); (2) combined PTA and bypass (245 cases); (3) more distal PTA of popliteal and tibial artery stenoses (233 cases); (4) use of in situ or ectopic reversed autogenous vein for infrapopliteal bypasses, even when vein diameter was 3 to 4 mm; (5) composite-sequential femoropopliteal-distal (PTFE/vein) bypasses; (6) reintervention when a procedure thrombosed (637 cases) or was threatened by a hemodynamically significant inflow, outflow, or graft lesion (failing graft, 252 cases); (7) frequent follow-up to detect threatening lesions before graft thrombosis occurred and to permit correction of lesions by PTA (58%) or simple reoperation; and (8) unusual approaches to all infrainguinal arteries to facilitate secondary operations, despite scarring and infection. Primary major amputation rates decreased from 41% to 5% and total amputation rates decreased from 49% to 14%. Aggressive policies to save threatened limbs thus are supported.

Long-Term Results of Combined Aortoiliac and Infrainguinal Arterial Reconstruction for the Treatment of Critical Limb Ischemia

“…Separation of the endovascular and surgical procedures will permit the use of the strategy in patients with early complications or inadequate dilatation before distal surgery. 16,17) However, some other authors successfully employed intraoperative angioplasty by surgically exposing the femoral artery and then proceeding directly to the distal surgical procedure. [18][19][20] The advantages of performing both procedures simultaneously in the operating suite are expediency and convenience for the patient, as the patient undergoes a single procedure, in addition to possible cost savings as a result of shorter hospital stays.…”

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

“…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. Although data on distal bypasses have not been encouraging, Veith and colleagues [5][6][7]17 improved their distal bypass results by using innovative and creative techniques, which resulted in a dramatic decrease in their procedure-related amputation rates (49% to 14%). Their distal bypass procedures, however, had a coincident 30-day mortality of 4% and 90-day graft failure rates of nearly 5%.…”

“…[5][6][7] The need for emergency surgery after tibioperoneal vessel angioplasty (TPVA), however, appears to be overstated. 8 This communication details the acute outcome of 235 CLI patients with 284 ischemic limbs who, often after ipsilateral inflow lesion balloon angioplasty, underwent balloon angioplasty of infrapopliteal tibioperoneal vessel outflow lesions.…”

Pedale Bypasschirurgie bei diabetischen Fußsyndrom: Indikation, Technik und Ergebnisse

“…Im Regelfall werden durch die Angiographie ausgedehnte arteriosklerotische Läsionen der femoropoplitealen Gefäßachse und vor allem der Unterschenkelarterien als Ursache der Ischämie aufgedeckt, während sich der für den unter Claudicatio intermittens leidenden Raucher typische Langstreckenverschluss der A. femoralis superficialis eher selten findet [31,58]. Für diese ausgedehnten arteriellen Verschlussprozesse stellt der Bypass die adäquate gefäßchir-urgische Maßnahme dar.…”