Extended reconstruction rate for limb salvage with intraoperative prereconstruction angiography

A prospective study was performed between May 1982 and March 1987 to assess the value of intraoperative prereconstruction angiography (IPA) in limb salvage. Eligibility was limited to patients with rest pain, ischemic ulcers, or gangrene limited to the toes: only candidates for infrapopliteal bypass were included. Seventy-eight such patients were examined with preoperative angiography. Delayed films, selective catheterization, reactive hyperemia, or vasodilators were used routinely. In only 11 of 78 patients (14%) was the runoff adequately visualized, demonstrating the tibial vessels and the pedal arch. The remaining 67 patients (86%) (with nonreconstructable disease by currently accepted outflow criteria) had surgical exposure of a tibial or pedal artery for IPA. In 56 of these patients (84%) good runoff was demonstrated and bypass was performed. The reconstruction rate was 86% (67 of 78 patients), significantly higher than the 33% rate reported by others. The operative mortality rate was 2.8% (2 of 78 patients). We concluded that in severe ischemia preoperative angiography is often inadequate in demonstrating runoff, even with adjunctive measures to dilate the outflow vessels. IPA through the tibial and pedal vessels eliminates all of the proximal vascular resistance, thereby providing a "completion angiogram" before reconstruction. This in turn extends reconstructability to many patients who would otherwise undergo primary amputation.