Revascularization of the ischemic diabetic foot using popliteal artery inflow

Between March 1988 and June 1994, 35 popliteal to distal artery vein bypasses were done in 32 diabetic patients. There were 16 males and 16 females with an average age of 60 years. Eighteen patients (56%) had insulin dependent diabetes mellitus. Medical risk factors included coronary artery disease (CAD) in 15 (47%), hypertension in 15 (47%), chronic renal failure (CRF) in 9 (28%), and cigarette smoking in 10 (31%). Indications for revascularization were: non-healing ulcerations in 18 (51%), gangrene in 15 (43%), and rest pain in 2 (6%). The distal anastomosis was to the posterior tibial artery in 9, anterior tibial artery in 8, dorsalis pedis artery in 10 and peroneal artery in 8 cases. All the bypasses were done with autogenous saphenous veins (in-situ 11, reversed 17, and free non-reversed 7). The limbs were graded into three groups based on the preoperative angiographic evaluation of their pedal arch: patent arch (Grade "0"), partial occlusion of the arch (grade "1.5") and little or no arch visualized (Grade "3"). Eight limbs had Grade "0", 16 had Grade "1.5" and 11 had Grade "3" pedal circulation. Bypass follow up was done by clinical exam and color duplex surveillance (CDS) for a mean duration of 24 months. CDS identified 4 failing bypasses which were surgically revised and have subsequently remained patent. There were 3 bypass occlusions which resulted in a major amputation in 2 patients. Three additional major amputations were performed for persisting infection despite a patent bypass. By life table analysis the cumulative primary & secondary patency and limb salvage rates for this group of diabetic patients were 75% at 2 years, 89% at 3 years and 82% at 3 years respectively (S.E. < 10%). The 3 bypass occlusions, which occurred at 1 week, 5 weeks, and 20 months, were in patients with both CRF and Grade "3" foot circulation (significantly different outcome compared to the rest of the group, by chi 2 test, p < 0.05). Good results can be achieved in the majority of diabetic patients undergoing short popliteal-distal bypasses. However, the combination of chronic renal failure and very limited foot circulation (Grade "3") has a significant adverse outcome.