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Infrapopliteal bypass for established gangrene of the forefoot or toes
Insights
Limb salvage is possible in two-thirds of patients with gangrene undergoing femorodistal bypass. Graft patency, achievable with repeat procedures, is key for successful limb salvage, even without saphenous vein grafts.
Area of Science:
- Vascular Surgery
- Limb Salvage Procedures
- Reconstructive Surgery
Background:
- Established gangrene poses a significant challenge for limb salvage.
- Femorodistal bypass is a critical intervention for patients with severe peripheral artery disease and limb-threatening ischemia.
Purpose of the Study:
- To identify factors influencing limb salvage success after femorodistal bypass in patients with established gangrene.
- To evaluate the long-term outcomes and graft patency rates associated with different graft materials and re-interventions.
Main Methods:
- Retrospective analysis of 71 femorodistal bypass procedures in 58 patients with forefoot/toe gangrene (1977-1983).
- Assessment of graft materials including autogenous saphenous vein, polytetrafluoroethylene (PTFE), and composite grafts.
- Life-table analysis for limb salvage rates and graft patency, with consideration for repeat procedures and thrombectomy.
Main Results:
- Limb salvage rates were 70% at 1 year, 60% at 3 years, and 28% at 5 years.
- Graft patency at 3 years was 65% for vein grafts versus 30% for PTFE grafts.
- Operative mortality was 1.7%; patient factors like age, sex, hypertension, or diabetes did not significantly impact outcomes.
Conclusions:
- Limb salvage is achievable in up to two-thirds of limbs with established gangrene via femorodistal bypass.
- Graft patency is essential for limb salvage and can be maintained through thrombectomy or repeat bypass procedures.
- Autogenous saphenous vein is preferred, but its absence should not deter limb salvage attempts; repetitive grafting improves limb survival without increasing patient risk.
Abstract:
This study was undertaken to assess factors affecting limb salvage after femorodistal bypass in patients with established gangrene. From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients: a single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases, polytetrafluoroethylene (PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot amputation with uncomplicated healing. Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for PTFE grafts. In the entire series the operative mortality rate was 1.7%. Age, sex, hypertension, or diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoropopliteal or tibial graft did not reduce the likelihood of limb salvage. Graft patency, however, is prerequisite for limb salvage, and graft patency can be maintained by thrombectomy or repetitive bypass. The present study suggests that limb salvage is possible in as many as two thirds of limbs with established gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival.