Fate of the limb after failed femoropopliteal reconstruction

Sixty-eight occluded femoropopliteal bypass grafts were studied to determine the fate of the limb after graft occlusion. There were 25 reversed saphenous vein grafts and 43 polytetrafluoroethylene grafts. Thirty-five limbs required amputation and the timing of amputation after graft thrombosis ranged from 1 day to 24 months. Twenty of the amputations occurred following an unsuccessful revision of the thrombosed graft and an additional 15 limbs were amputated without further attempts at revascularization. In 17 of the patients there were no disabling signs or symptoms after graft occlusion. Twenty-two grafts were successfully revised to avoid amputation. The need for amputation and the level of amputation were analysed with respect to the age of the patient, the indication for the original procedure, inflow and outflow status, the type of graft and the level of distal anastomosis. In 26 patients with intermittent claudication only four amputations resulted from graft occlusion and these were all below the knee. There was a weakly significant (P less than 0.1) correlation between poor outflow and the need for amputation after occlusion of the graft. In particular, patients with femorodistal bypass faired poorly, four of five occluded saphenous vein grafts and all six PTFE grafts requiring amputation. There was no significant age difference with respect to the level of amputation or the need for amputation and there was a wide range from the time of thrombosis to amputation. The authors conclude that amputations are infrequent after bypass grafting for claudication. The level of distal anastomosis, poor inflow and run-off and gangrene before the bypass procedure all correlate with the need for amputation in thrombosed grafts initially placed for limb salvage. Vigorous attempts at revision of failed grafts may prevent or constructively delay amputation.