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Value of continued efforts at limb salvage despite multiple graft failures
S M George1, T W Klamer, G E Lambert
1Department of Surgery, University of Louisville School of Medicine, Ky.
Insights
For patients with limb-threatening ischemia, third or fourth infrainguinal bypasses after previous failures offer a chance for limb salvage. Despite risks, revascularization improves ambulation and quality of life for many.
Area of Science:
- Vascular Surgery
- Limb Salvage Procedures
- Infrainguinal Bypass
Background:
- Limb-threatening ischemia after multiple failed bypasses presents a significant clinical challenge.
- Revascularization attempts after prior failures are often considered controversial or futile.
Purpose of the Study:
- To evaluate the efficacy of third or fourth infrainguinal bypass procedures in patients with previously failed revascularizations.
- To determine limb salvage rates and long-term outcomes for repeat bypass surgeries.
Main Methods:
- A retrospective review of 312 infrainguinal bypasses performed between 1983 and 1992.
- Analysis of 16 patients who underwent third or fourth bypass procedures for limb salvage after two or more prior failures.
Main Results:
- The overall limb salvage rate was 84% across all patients.
- In the subset of 16 patients undergoing tertiary/quaternary bypasses, there were no operative deaths.
- Sixty-two percent of these patients survived over 3 years, with half maintaining graft patency and quality of life.
Conclusions:
- Despite a higher risk of graft failure and limb loss, repeat infrainguinal bypasses are justified for limb salvage.
- Revascularization in this high-risk group significantly improves ambulation compared to amputation.
- Continued efforts in limb salvage are warranted even after multiple previous bypass failures.
Abstract:
Treatment of patients with limb-threatening ischemia after multiple failed bypasses remains difficult and controversial. Further revascularization procedures despite failure of the original procedure may be viewed as futile. The purpose of this report is to determine the efficacy of third or fourth revascularization procedures after the original and second procedures fail. Over a 10-year period from January 1, 1983, to December 31, 1992, 312 infrainguinal bypasses were performed on 271 consecutive patients for foot salvage. The overall limb salvage rate was 84%, and the operative mortality rate was 3.7% (10 patients). Sixteen patients (5.8%) had repeat infrainguinal bypasses performed after failure of two or more prior bypass procedures in the same leg. Twenty-three reconstructions were performed in these 16 patients. There were no operative deaths. One half of these patients had major amputations performed within the first year following their tertiary or fourth reconstructive procedure. Sixty-two percent of patients have survived longer than 3 years after their third or fourth procedure. One half of these patients have maintained graft patency and an excellent quality of life. Only 22% of the patients requiring amputation ambulated with a prosthesis, whereas all revascularized patients ambulated. Although this subset of patients is known to have an increased risk of repeated graft failure and limb loss, we believe continued efforts at limb salvage despite multiple previous graft failures is justified.
