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Pedal and distal lower leg bypasses with a distal arteriovenous fistula
D P van Berge Henegouwen1, G Stelzer, T Dautzenberg
1Klinik Oberwald, Fachklinik für Gefäss und Enddarmerkrankungen, Grebenhain, West Germany.
Insights
Distal tibial or pedal bypasses with arteriovenous fistula improved limb salvage in patients with critical limb ischemia. This revascularization strategy offers hope for preventing amputation in severe cases.
Area of Science:
- Vascular Surgery
- Diabetic Foot Complications
- Reconstructive Surgery
Background:
- Critical limb ischemia often presents with severe rest pain or gangrene, particularly in diabetic patients.
- Lower leg block (LLB) characterized by occlusions in tibial arteries necessitates advanced revascularization techniques.
- Traditional bypasses may fail due to poor distal outflow in complex arterial disease.
Purpose of the Study:
- To evaluate the efficacy of distal tibial or pedal bypasses combined with arteriovenous fistula (AVF) for limb salvage.
- To assess the patency rates and limb salvage outcomes in patients with severe lower extremity arterial disease.
- To explore the role of revascularization in preventing amputations in 'hopeless' cases.
Main Methods:
- Forty patients underwent 41 revascularization procedures using distal tibial or pedal bypasses.
- A side-to-side arteriovenous fistula (AVF) was added to the distal anastomosis to enhance outflow.
- Patients had severe rest pain or gangrene, with angiographic evidence of lower leg block.
Main Results:
- A limb salvage rate of 79% and a bypass patency rate of 67% were achieved at a mean follow-up of 21 months.
- Despite complications like cellulitis, revascularization prevented amputation in many severe cases.
- Bypass occlusion did not always lead to recurrent gangrene, indicating successful initial revascularization.
Conclusions:
- Distal bypass surgery, augmented with an AVF, is a viable option for limb salvage in patients with severe limb ischemia and complex arterial disease.
- This technique can prevent amputations even in angiographically challenging cases.
- Careful patient selection and management are crucial to overcome complications and optimize outcomes.
Abstract:
In forty patients 41 feet were revascularised by means of distal tibial (the distal 10 cm of the lower leg) (17) or pedal bypasses (24). Angiographically the preoperative state was best defined as a lower leg block (LLB); All three arteries showing occlusions at several levels, leaving only isolated functioning arterial segments in the distal leg or foot with relatively good femoral and popliteal arteries. As might be expected this condition was mainly found in diabetics (75%). Only feet with severe rest pain (4) or rest pain with gangrene (37) were operated upon. To improve the distal outflow a side-to-side arteriovenous fistula (AVF) was added to the distal anastomosis. With a mean follow-up of 21 months (1-40 months) the limb salvage rate was 79% and the patency rate 67%. Special problems were experienced with cellulitis of the foot, causing the loss of three feet despite an open bypass and sufficient revascularisation. Furthermore, occlusion of the bypass after healing of the lesion did not necessarily mean a recurrence of gangrene. As this series shows, even in angiographically apparently hopeless cases, a bypass to the foot can prevent an otherwise unavoidable amputation.