Critical Evaluation of Endovascular Surgery for Limb Salvage

Abstract

Rest pain, tissue loss, and gangrene are manifestations of critical limb ischemia caused by peripheral arterial disease and define a patient subgroup at highest risk for major limb amputation. Patients with nonhealing lower extremity wounds should be screened for the risk factors for peripheral arterial disease and offered noninvasive vascular testing. The diagnosis of critical limb ischemia mandates prompt institution of medical and surgical management to achieve the best chance of limb salvage. Surgical intervention has evolved from primary amputation to open bypass to the present era of endovascular therapy. The goals of surgical bypass and endovascular therapy are to improve perfusion sufficiently to permit healing. Despite poorer patency rates and the more frequent need for reintervention, endovascular therapy has been shown in multiple retrospective studies to achieve limb salvage similar to open bypass. Only one large, prospective, randomized controlled trial exists comparing open bypass with endovascular therapy: The Bypass versus Angioplasty in Severe Limb Ischemia of the Leg (BASIL) trial. Close clinical surveillance and serial monitoring of limb perfusion by means of noninvasive arterial studies are needed to determine the need for further vascular intervention. Limb salvage patients suffer from multiple comorbidities and benefit from a multidisciplinary, team approach to care.

Negative Pressure Wound Therapy over the Achilles Tendon for Medically Compromised Ambulatory Patients

“…However, free flaps may be not good choices when adequate recipient vessels are absent [3]. Endovascular angioplasty combined with free soft tissue transfer has been common over the past decade for limb salvage but has a high restenosis rate and is relatively contraindicated in patients with severe chronic renal insufficiency [4,5]. A cross-leg flap requires prolonged immobilization, longer hospitalization, and additional procedures for flap division [6].…”

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

“…1, 2 Over the past two decades, infrainguinal endovascular intervention (IEI) has gained widespread acceptance and is now more commonly performed than LEB. 3, 4 Intuitively, IEI should have the advantage of lower procedural risk in the complex critical limb population with multiple medical comorbidities. 2, 5 However, data directly comparing LEB and IEI remains sparse.…”

Preface to Current Concepts in Wound Healing: Update 2011

“…12,13 While traditional open bypass surgery has demonstrated excellent long-term results, endovascular surgery has encouraging shortterm results. With improving endovascular techniques, the outcomes have continued to improve.…”