Results of revascularization and amputation in severe lower extremity ischemia: A five-year clinical experience

Abstract

Aggressive revascularization of the ischemic lower extremity in atherosclerotic occlusive disease by femoropopliteal (FP) and femorotibial (FT) bypass or profundaplasty (P), as indicated, has been advocated by some authors for all patients. Others have recommended primary amputation, particularly for tibial occlusive disease. To clarify this clinical dilemma, we reviewed the results of 547 procedures performed during the last 5 years: revascularization in 375 (69%) instances and below-knee amputation (BKA) in 172 (31%) cases. Bypass procedures were used in 246 cases: FP in 155 (64%) and FT in 91 (37%). Reversed autogenous saphenous vein (ASV) was used preferentially in 125 (51%) cases, whereas polytetrafluoroethylene (PTFE) was used in 121 (49%) cases. P was performed in 129 instances accompanied by inflow procedures in 92 (71%) of these cases. Cumulative limb salvage (LS) exceeded bypass patency in all categories and resulted in 2- and 5-year LS rates of 83% and 81% for FP with the use of ASV and 52% and 35% for PTFE. The LS rate for FT was 53% and 47%, respectively, for ASV and 20% and 15% for PTFE. Rest pain was successfully relieved by P in 99 cases (77%), whereas healing occurred in only 51% of cases with tissue loss. The perioperative mortality rate for revascularization was 3%; 42% of the group died during follow-up, death usually resulting from complications of atherosclerosis. Of the 172 BKAs, primary healing occurred in 80%, but the perioperative mortality rate was 13%. FP and FT bypasses are preferred procedures if ASV is available, whereas use of PTFE should be limited to FP bypasses only. Rest pain is relieved by P but tissue loss should prompt consideration for bypass. BKA should be considered in cases of severe tibial disease only in the absence of a suitable ASV, as the perioperative mortality rate is high and ultimate rehabilitation (64%) is limited.

Major Lower Extremity Amputation

“…The 30-day mortality rate of 8.6% in this series is consistent with that of previously reported data. [11][12][13] Systemic complications encountered in this series approximated those documented in previously published reports. 14 Not surprisingly, complications of cardiac nature, such as myocardial infarction, arrhythmias, and congestive heart failure, were the most common and were documented in 10.2% of cases.…”

Outcomes of a Contemporary Amputation Series

“…Although cumulative mortality at 30 days in our series was low (10.1%), more than half the patients were not alive at 2 years and nearly 60% had died by the cessation of data collection. Several recently published papers have noted that increases in the rates of vascular reconstructive procedures for peripheral arterial occlusive disease of the lower limbs have not resulted in a decrease in mortality 1,11,16–18 . This may be a result of a changing amputee population; individuals who would have previously undergone an MLLA in years past may instead be offered a revascularization procedure, thus leaving more debilitated patients in the amputee group 11 .…”

Strategies in Infrapopliteal Intervention: Improving Outcomes in Challenging Patients

“…9,10 Two-year patency rates of 20% to 38% have been reported in below the knee bypasses utilizing prosthetic grafts. 11,12 Several new surgical techniques have been reported that appear promising. These include utilizing PTFE grafts with interposition of venous tissue at the distal anastomosis and anticoagulant bonded synthetic inner lumens.…”

“…The standard indications for tibioperoneal intervention are severe, lifestyle-limiting claudication despite optimal medical therapy, rest pain, nonhealing ulcers, or gangrene of the lower extremity. [5][6][7] Preprocedure Evaluation. In patients presenting with CLI, noninvasive studies are not really necessary prior to performing diagnostic angiography.…”