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Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot
P Gloviczki1, T C Bower, B J Toomey
1Division of Vascular Surgery, Mayo Clinic and Foundation, Rochester, Minnesota 55905.
Insights
Pedal bypass surgery is a safe and effective treatment for critical limb ischemia, offering good durability and limb salvage rates, even in high-risk patients. This procedure should be considered before amputation.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Ischemia Management
Background:
- Chronic critical limb ischemia poses significant risks, necessitating evaluation of surgical interventions.
- Pedal bypass procedures are increasingly utilized for limb salvage in complex cases.
Purpose of the Study:
- To assess the operative risks associated with pedal bypass.
- To determine the long-term durability and success rates of pedal bypass.
- To identify factors influencing the outcome of pedal bypass surgery.
Main Methods:
- Prospective observation of 96 patients undergoing 100 pedal bypasses for chronic critical ischemia.
- Utilized autogenous vein grafts (saphenous, composite, reversed) with various distal anastomoses.
- Employed operating microscope for precise distal anastomoses to pedal arteries.
Main Results:
- Zero perioperative mortality; low rates of myocardial infarction and wound complications.
- Achieved 60% primary and 69% secondary patency rates at 3 years.
- Demonstrated a 79% cumulative foot salvage rate at 3 years; higher secondary patency linked to intraoperative flow and diabetes.
Conclusions:
- Pedal bypass is a safe and effective procedure for critical limb ischemia.
- The durability of pedal bypass supports its use as an alternative to major amputation.
- Consideration of pedal bypass is recommended for high-risk patients facing potential amputation.
Background:
The aim of this study was to determine the current operative risks of the pedal bypass procedure, its durability, and the factors affecting long-term outcome.
Methods:
We prospectively observed 96 patients who consecutively underwent 100 pedal bypasses using autogenous vein grafts for chronic critical ischemia. Of the 100 limbs, 91 had ischemic ulcers or gangrene, and 9 produced rest pain only. Sixty-four patients were diabetic, 21 had renal failure, and 36 had coronary artery disease. Nonreversed saphenous vein grafts were used most frequently (68 translocated, 13 in situ), followed by composite (13) and reversed vein grafts (6). Fifty-two long grafts originated from the iliac or femoral arteries, and 48 short grafts originated from the popliteal or tibial arteries. For the 100 procedures, 102 distal anastomoses were performed--68 to the dorsalis pedis, 8 to the distal posterior tibial, 10 to the common plantar, 2 to the medial plantar, 9 to the lateral plantar, 4 to the lateral tarsal, and 1 to the first dorsal metatarsal arteries--with the aid of an operating microscope.
Results:
No patient died during the perioperative period. Two had hemodynamically insignificant myocardial infarctions. Wound complications developed in 12 patients--infection in 7 and hematoma in 5. There were 10 early graft failures, 6 of which could be salvaged, and 96 grafts were patent at dismissal. Mean follow-up was 2.1 years (range 1 month to 6.4 years). Postoperative surveillance identified 33 failed or failing grafts, 16 of which were successfully revised. At 3 years, cumulative primary and secondary patency rates were 60% and 69%, respectively. Factors correlating with increased secondary patency were intraoperative flow rate > or = 50 mL/min (P = 0.004) and diabetes (P < 0.05). Major amputations were performed on 17 limbs. The cumulative foot salvage rate at 3 years was 79%.
Conclusion:
Pedal bypass is a safe, effective, and durable procedure. It should be considered even for high-risk patients with critical limb ischemia before major amputation is contemplated.