[Importance of pedal bypass in limb salvage]

In 2000 to 2002, we carried out "pedal" arterial reconstructions in 30 patients, performing a distal anastomosis to the dorsal pedal artery (47%) or the posterior tibial artery (53%). All patients suffered from critical ischemia of the lower extremity; 26 (86.7%) had gangrene or foot defect and 21 (70%) had diabetes mellitus. They all had atherosclerotic obliteration of the crural arteries and only a graft bypass of this segment offered good prospects for limb salvage. In 16.7% of the patients, previous percutaneous transluminar angioplasty had failed to treat the condition. Preoperative angiographic findings were unsatisfactory in the majority of patients because in 23 patients (76.7%) the plantar arch was not shown and, in 13 patients (43.3%), neither the plantar arch nor any of the pedal arteries were visualised. During 36 months of follow-up, one patient died (3.3%) and three had bypass graft occlusion (10%). Of these, one patient underwent early thrombectomy, which resulted in long-term graft patency and limb salvage. A further patient had the limb saved although occlusion occurred after the defect had healed. In the third patient, however, bypass occlusion eventually led to high amputation of the leg. The results were evaluated by Kaplan Meier analysis. At 36 months, cumulative probabilities were 87% and 90% for primary and secondary patency, respectively; cumulative probability for limb salvage was 93%. Our results are in agreement with those from major specialised foreign centres and support the view that patients with critical ischemia and unsatisfactory angiographic findings (obliteration of crural arteries) are indicated for pedal artery inspection with subsequent vascular reconstruction.