Interval gangrene occurring after successful lower-extremity revascularization

Four patients experienced a rare but devastating complication of peripheral vascular reconstructive surgery in which gangrene occurred in the presence of a functioning graft and palpable pulse. Three patients underwent bypass procedure for limb-threatening ischemia. Despite a "satisfactory" postoperative result of a well-perfused distal extremity and strongly palpable pulse, each of these patients developed progressive ischemic gangrene in an area proximal to the distal anastomosis and eventually required amputation. These patients demonstrate the importance for maintaining collaterals to perfuse bypassed segments of the lower extremities. In a patient with inadequate collateral circulation or in whom the profunda perigeniculate collateral pathway has been disrupted or is absent due to disease, it is necessary to revascularize sequential vascular beds.