Limb loss despite functioning distal bypass

Five patients are reported who failed to heal ischemic foot wounds despite patient, functioning in situ saphenous vein grafts to infrapopliteal arteries. All were diabetic and two died before amputation could be performed. Contributing to this paradoxical failure of attempted limb salvage were: (a) extensive preexistent gangrene, (b) infection and failure of wound management, and (c) occlusive disease in runoff beds despite the distal site of anastomosis. Distal occlusive disease included one or more of the following: (a) stenosis in a named artery of the foot, (b) stenosis of collaterals from the peroneal artery, and (c) incomplete pedal arches. Distal in situ saphenous vein bypass should continue to be broadly applied for limb salvage, but careful judgement in patient selection and attention to the management of the ischemic wound itself remain critical to success.