Simultaneous versus two-stage multisegmental reconstruction for critical lower limb ischemia
1Department of Surgery, Mubarak Al-Kabeer Hospital, Kuwait, and Department of Vascular Surgery, Vilnius University, Lithuania.
Insights
Simultaneous multisegmental reconstructions for critical limb ischemia (CLI) are safer and more effective than two-stage surgeries. This study found better limb salvage and graft patency rates with the one-stage approach.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Surgical Outcomes
Background:
- Critical limb ischemia (CLI) due to multisegmental arterial disease presents significant surgical challenges.
- Established treatment options include inflow procedures, simultaneous inflow/outflow reconstructions, or two-stage surgery.
Purpose of the Study:
- To compare the outcomes of simultaneous versus two-stage aortofemorodistal reconstructions for treating critical limb ischemia.
- Evaluate perioperative and long-term results, focusing on limb salvage and graft patency.
Main Methods:
- Retrospective analysis of 245 patients undergoing aortofemorodistal reconstructions for CLI (Grade III and IV Fountain).
- Group A: 161 patients with simultaneous two-segment reconstruction.
- Group B: 84 patients with two-stage surgery (outflow after inflow).
- Life table method used for analyzing limb salvage and graft patency rates.
Main Results:
- Perioperative mortality was lower in the simultaneous group (3% vs. 6%).
- One-year limb salvage rates: 95.6% (Group A) vs. 88.8% (Group B).
- Five-year limb salvage rates: 90.4% (Group A) vs. 80% (Group B).
- Higher primary and secondary graft patency rates observed in Group A at both one and five years.
Conclusions:
- Simultaneous multisegmental reconstructions for critical limb ischemia are a safe and effective treatment modality.
- The one-stage approach demonstrates superior outcomes in terms of limb salvage and graft patency compared to two-stage surgery.
Abstract:
Treatment of critical limb ischemia (CLI) remains one of the most demanding problems of vascular surgery, especially when it is due to multisegmental occlusive arterial disease. Three main options of treatment are accepted: inflow procedure alone, simultaneous inflow and outflow reconstructions, or two-stage surgery. To compare the results of the latter two was the aim of this study. During a six year period from 1987 to 1992, 1953 aortofemoral reconstructions were performed. In 245 cases (12.5%), sequential aortofemorodistal (popliteal or tibial) procedures were necessary for successful treatment of CLI - Grade III and IV Fountain. In 161 cases, two-segment reconstruction was performed in one stage (Group A), and in 84 cases (Group B), two separate operations were done - outflow procedure followed after the inflow surgery. Results in perioperative and remote postoperative periods were analyzed regarding limb salvage and graft patency rates using a life table method. Perioperative mortality was 3% in Group A and 6% in Group B. The limb salvage rate was 95.6% at one year and 90.4% at five(A), and 88.8% and 80% (B) respectively. Primary overall graft patency rate was 91.4% at one year and 65.5% at five (A) and 84.9% and 59.4% (B) respectively. Secondary graft patency was 92.2% at one year and 81.8% at five (A) and 86.1% and 65.9% (B). Analysis of the data demonstrates that simultaneous multisegmental reconstructions for critical limb ischemia are a safe and effective method of treatment and superior when compared with two-stage surgery.
