Tourniquet occlusion technique for tibial artery reconstruction

Vascular clamps, vessel loops, and intraluminal occluding devices used to control tibial and pedal vessels can be injurious and may fail to occlude heavily calcified arteries. In an effort to prevent injury to these small arteries, we have investigated the safety and efficacy of thigh pneumatic tourniquet occlusion for distal vascular control during infrapopliteal reconstruction.

During an 18-month period, 88 tibial or pedal arterial reconstructions were performed on 80 patients (mean age 75 years) by the tourniquet technique. Data regarding indications for operation, preoperative evaluation, intraoperative findings, surgical technique, and early outcome were recorded prospectively.

Sixty percent of patients were diabetic: 36% insulin dependent and 24% non-insulin dependent. The indications for operation were claudication in 6 (7%), ischemic ulcer in 24 (27%), rest pain in 25 (28%), and gangrene in 33 (38%) patients. Thirty-five percent of operations followed failed ipsilateral infrainguinal reconstructions. The peroneal artery was the target vessel in 38%, anterior tibial in 26%, posterior tibial in 23%, tibioperoneal trunk in 9%, and inframalleolar vessels in 4% of cases. Preoperative analog waveforms and ankle-brachial indexes were used to classify the tibial arteries as compliant, 49%; relatively noncompressible, 30%; and absolutely noncompressible, 9%. Twelve percent had no Doppler flow at the ankle level. At operation 36 of the target arteries (41%) had mural calcification. Tourniquet pressures of 200 to 400 mm Hg (mode 250 mm Hg) were applied from 13 to 55 minutes (mean 27.1 +/- 9.1 minutes). All patients were given systemic anticoagulants. In 19 limbs (22%) the tourniquet was used to occlude a patent superficial femoral artery above the proximal (inflow) anastomosis to either the superficial femoral artery (8%), the above-knee popliteal artery (5%), or the below-knee popliteal artery (9%). Hemostasis was adequate in all cases and no alternative occlusive devices were required. There were no significant complications attributable to the use of the pneumatic tourniquet.

Tourniquet occlusion simplifies the infrapopliteal dissection, lessens operating time, improves visualization of the distal anastomosis, and removes the potential for arterial injury to the target vessel. Arterial calcification and noncompressible tibial arteries do not contraindicate the use of thigh tourniquet occlusion. This technique is preferred for all patients undergoing tibial or pedal artery reconstruction.