Amputation level and distal bypass salvage of the limb

The feasibility of revascularization of the lower extremity for salvage of the limb with grafts to the tibial and peroneal arteries has been well established. The results of prior reports have suggested that a failed distal bypass may convert a lower extremity amputation to a higher level than afforded by primary amputation. We reviewed all distal, tibial or peroneal artery bypasses performed at our institution during the period of March 1980 through October 1986. Fifty-three patients with 59 threatened lower extremities underwent distal bypass for salvage of the limb. No patient was excluded from review. Thirty-eight patients in the study group had diabetes, and 41 had a prior smoking history. In the postoperative period, six patients were lost to follow-up study, nine patients died, with follow-up data complete in 47 of the study group. The maximum length of follow-up study was 78 months, and the average length was 24 months. Data were examined by life table analysis with respect to cumulative salvage of the limb and graft patency. During the period of review, 12 major amputations were required (nine below-knee and three above-knee) for a cumulative salvage rate of 59 per cent. Of the distal grafts which failed (n = 27), three of 27 of the limbs required above-knee amputation. We conclude that a failed tibial or peroneal artery bypass does not preclude the possibility of salvage of the limb and does not predispose to a subsequent amputation.