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Do results justify an aggressive strategy targeting the pedal arteries for limb salvage?
J G Robison1, M A Cross, T E Brothers
1Medical University of South Carolina, Ralph A. Johnson VA Medical Center, Charleston 29425, USA.
Insights
Pedal bypass surgery offers a viable solution for limb salvage in patients with critical limb ischemia. This strategy demonstrates acceptable long-term graft patency and limb salvage rates, especially when compared to peroneal bypass for forefoot tissue loss.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Ischemic Limb Disease Management
Background:
- Limb-threatening ischemia often involves complex infrapopliteal arterial disease.
- Bypass to pedal arteries is an alternative strategy for limb salvage.
- Outcomes of pedal bypasses require further evaluation.
Purpose of the Study:
- To evaluate the long-term outcomes of infrapopliteal bypasses to pedal arteries for limb salvage.
- To compare pedal bypass outcomes with peroneal bypass in specific clinical scenarios.
- To assess the impact of pedal bypass on graft patency and limb salvage rates.
Main Methods:
- Retrospective analysis of 194 infrapopliteal bypasses for limb salvage between 1986 and 1992.
- Focus on 111 autogenous vein bypasses to pedal vessels (at or distal to the ankle).
- Life table analysis used to determine primary and secondary patency, and limb salvage rates.
Main Results:
- Primary graft patency at 60 months was 57%, with secondary patency at 61%.
- Limb salvage rate at 60 months was 64%.
- Pedal bypass showed superior limb salvage compared to peroneal bypass in cases of forefoot necrosis (63% vs. 33% at 36 months).
Conclusions:
- Pedal bypass surgery provides acceptable long-term patency and limb salvage for critical limb ischemia.
- Pedal bypass is a preferable option to peroneal bypass when forefoot ischemic tissue loss is present.
- Graft thrombosis significantly impacts limb loss, highlighting the importance of graft maintenance.
Abstract:
We initiated a strategy to bypass all of the significant popliteal and tibial disease in the setting of limb-threatening ischemia beginning in September 1986. Of 194 infrapopliteal bypasses performed for limb salvage during the ensuing 6 years, 111 (57%) autogenous vein bypasses were performed to the pedal vessels at or distal to the ankle. By life table analysis, primary graft patency at 60 months for pedal bypasses was 57%, with salvage of failed grafts resulting in secondary patency of 61%. Limb salvage was 64% at 60 months. Of 33 graft thromboses, 24 (73%) resulted in eventual limb loss. Five limbs were amputated due to wound complications or progressive forefoot sepsis despite patent pedal grafts. More bypasses were performed to the dorsalis pedis than the posterior tibial at the ankle (78 vs 33), but patency and limb salvage were similar. Bypasses to the pedal arteries resulted in superior limb salvage compared with peroneal bypass when forefoot tissue necrosis was present (63 vs 33% at 36 months, P = 0.048). Pedal grafts had comparable overall patency (57 vs 64%) and limb salvage (64 vs 75%) to more proximal tibial bypasses. Pedal bypass provides acceptable long-term outcomes for both patency and limb salvage. When forefoot ischemic tissue loss is present, pedal bypass, when feasible, appears preferable to peroneal bypass.