Combined free tissue transfer and infrainguinal bypass graft: An alternative to major amputation in selected patients (original) (raw)
Related papers
Limb salvage after infrainguinal bypass graft failure
Journal of Vascular Surgery, 2004
The purpose of this study was to examine the outcome of patients in whom an infrainguinal bypass graft failed. Methods: This was a retrospective analysis of consecutive patients undergoing infrainguinal bypass grafting in a single institution over 8 years. Results: Six hundred thirty-one infrainguinal bypass grafts were placed in 578 limbs in 503 patients during the study period. The indication for surgery was limb-threatening ischemia in 533 patients (85%); nonautologous conduits were used in 259 patients (41%), and 144 (23%) were repeat operations. After a mean follow-up of 28 ؎ 1 months (median, 23 months; range, 0-99 months), 167 grafts (26%) had failed secondarily. The rate of limb salvage in patients with graft failure was poor, only 50% ؎ 5% at 2 years after failure. The 2-year limb salvage rate depended on the initial indication for bypass grafting: 100% in patients with claudication (n ؍ 16), 55% ؎ 8% in patients with rest pain (n ؍ 49), and 34% ؎ 6% in patients with tissue loss (n ؍ 73; P < .001). The prospect for limb salvage also depended on the duration that the graft remained patent. Early graft failure (<30 days; n ؍ 25) carried a poor prognosis, with 2-year limb salvage of only 25% ؎ 10%; limb salvage was 53% ؎ 5% after intermediate graft failure (<2 years, n ؍ 110) and 79% ؎ 10% after late failure (>2 years, n ؍ 15; P ؍ .04). Multivariate analysis revealed shorter patency interval before failure (P ؍ .006), use of warfarin sodium (Coumadin) postoperatively (P ؍ .006), and infrapopliteal distal anastomosis (P ؍ .01) as significant predictors for ultimate limb loss. Conclusion: The overall prognosis for limb salvage in patients with failed infrainguinal bypass grafts is poor, particularly in patients with grafts placed because of tissue loss and those with early graft failure.
Mortality and limb loss with infected infrainguinal bypass grafts
Journal of Vascular Surgery, 1987
A recent experience with infrainguinal graft int~tions was reviewed in an effort to identify factors related to limb loss and mortality. The records of 32 patients who had operative treatment of 33 episodes of infrainguinal graft infection between 1978 and 1985 were reviewed to evaluate the effects of 20 factors possibly affecting outcome. The amputation rate was 79%. Of the 20 factors studied, only the presence of overt limb sepsis was associated with the need for amputation, with 100% of patients having limb sepsis requiring amputation vs. 72% of patients without limb sepsis (p = 0.03). The in-hospital mortality rate was 22%. Eighty-six percent of the deaths were due to ongoing sepsis. Again, a single factor was associated with death. Five of the 12 patients (42%) in whom preservation of axial flow was attempted died in contrast to only 2 of 20 patients (10%) who did not have attempted arterial reconstruction (p = 0.04). Limb salvage did not occur in any of the patients in whom preservation of axial flow was attempted and nine required above-knee amputation. Thirteen of the remaining 20 patients had occluded femoral vessels either because of operative figation (nine) or previous thrombosis (four). Above-knee amputations healed in all but one of these 13 patients. Determined attempts at increasing limb preservation were associated with no improvement in amputation rate or level and were accompanied by an unacceptably high mortality rate. Aggressive control of sepsis through the early amputation of septic limbs after graft removal may improve survival without further detriment to limb preservation.
Combined arterial reconstruction and free tissue transfer for limb salvage
Journal of Vascular Surgery, 1999
Lower-extremity arterial anatomy that is insufficient for successful vein bypass grafting and major proximal foot wounds often lead to leg amputation in patients with severe ischemia. Free tissue transfer, which can provide limb salvage in these patients after arterial reconstruction, was studied. Methods: During a 45-month period, 21 patients who otherwise would have undergone leg amputation were treated with arterial bypass by means of vein grafting and free tissue transfer. Ages of the patients ranged from 40 to 73 years (average, 59 years); 18 of the 21 patients had diabetes mellitus; and all patients except one were men. Arterial reconstruction was performed from the femoral (nine of 21 patients) or popliteal artery (12 of 21 patients) to the posterior tibial (eight patients), dorsalis pedis (five patients), peroneal (three patients), popliteal (one patient), or anterior tibial artery (one patient), or directly to the free flap (three patients). The tissue transferred included latissimus dorsi (five patients), rectus abdominus (five patients), omentum (five patients), gracilis (two patients), radial forearm flaps (three patients), and a scapular flap (one patient). Foot defects were debrided, including the appropriate toe or transmetatarsal amputation, covered with the transferred flap, and then split-thickness skin grafted. Arterial flow for all flaps was through the vein grafts, with direct arterial anastomosis and with venous outflow through adjacent tibial veins. Results: All 21 procedures were successful initially, without operative mortality, but three failed within 4 weeks because of uncontrolled infection (two) or embolization from a remote site (one) and required below-knee amputation. Grafts remained patent in 18 procedures, and follow-up of this cohort ranged from 1 to 45 months (mean, 13.3 months). Two patients died, one after 4 months and one after 6 months, of unrelated illness; at the time of death, they had functioning grafts. The remaining 19 patients are alive. Of these, 15 have patent arterial grafts, all viable free flaps. Thus, limb salvage was accomplished in 18 of 21 (86%) patients who otherwise would have required below-knee amputation. Conclusion: Patients destined for leg amputation despite aggressive traditional arterial bypass grafting methods can achieve limb salvage with the additional technique of free tissue transfer.
European Journal of Vascular and Endovascular Surgery, 2012
Introduction and objectives: Infrainguinal bypass surgery (BPG) is accompanied by significant 30-day mortality and morbidity, including early graft failure. The goal of this study is to identify patient-and procedure-specific factors which predict the rate of early graft failure in contemporary practice. Methods: Data was obtained from the private sector National Surgical Quality Improvement Program, a prospective, validated database collected between 2005 and 2008 from 211 hospitals, using primary and modifier Current Procedural Terminology codes for BPG. The primary endpoint was graft failure at 30 days. Procedural parameters, patient demographics and clinical variables were analyzed by univariate and multivariate methods. Results: There were 9217 BPG procedures (limb salvage, 49%; infrapopliteal distal anastomosis, 43%; prosthetic 32%) with patient variables: age 67 AE 12 years, male 64%, diabetes 44%, dialysis 7.4%. Mortality was 2.4%, major morbidity was 17.3%, and graft failure rate was 6.3% at 30 days. Multivariate predictors of graft failure demonstrated correlation (p-value, OR) with female gender (p ¼ 0.0054, 1.29), limb salvage indication (p < 0.0001, 1.60), infrapopliteal anastomosis (p < 0.0001, 2.15), composite graft (p ¼ 0.0436, 1.82), current smoking (p ¼ 0.0007, 1.36), impaired sensorium (p ¼ 0.0075, 2.13), emergency procedure (p < 0.0001, 2.03), previous vascular procedure (p ¼ 0.0005, 1.39), and platelets >400K (p ¼ 0.0019, 1.49). High-risk composite constructs utilizing these significant predictive factors can identify cohorts of patients with up to a 98-fold increase in odds of early graft failure. Conclusions: These results describe common risk factors that correlate with early graft thrombosis including the unique description of its association with thrombocytosis. Additional risk factors thus identify a subset of patients who are at highest risk for early BPG failure. This data may be used to refine patient selection.
Journal of Vascular Surgery, 2002
This study tested the hypothesis that a subset of secondary infrainguinal arterial reconstructions show prohibitive failure rates. Methods: Records of 79 consecutive patients, 44 men and 35 women, with a mean age of 60 years, who underwent secondary infrainguinal bypass from 1992 to 2000 at the University of Michigan Hospital, were reviewed. Data were analyzed with life-table analysis, logistic regression, and descriptive statistics. Results: Secondary infrainguinal reconstructions were performed in patients who had undergone earlier ipsilateral bypasses once (n ؍ 35) or twice (n ؍ 44). Among the prior procedures, 68% (n ؍ 54) were done at an institution other than the authors'. Comorbidities included coronary artery disease (72%), tobacco use (77%), and diabetes mellitus (34%), but no patient had hemodialysis-dependent renal failure. Disabling claudication, with average ankle brachial index of 0.48, had been the indication for the primary operation in 77% of cases. Femoral-popliteal bypass was the primary procedure in 67%, with a prosthetic graft used in 62%. The mean patency duration of these earlier bypasses was 25 months. The indication for the final bypass was rest pain or tissue loss in 51% of patients, with an average ankle brachial index of 0.37. The most common procedure was a femoral-distal bypass with autologous vein (63%). Mean patency duration of the secondary bypasses was 30 months. Graft failure within 30 days of operation occurred in 22 patients (28%), and amputation was necessitated in 86% of these patients. The presence of rest pain or tissue loss, when accompanied with a history of early prior graft thrombosis in female patients, correlated with worse mean patency rates, recurrent graft failure (P < .05), and a 94% amputation rate. Men in a similar setting incurred a 57% amputation rate. No association of final patency existed with regard to age, number of prior bypasses, conduit types, tobacco use, or diabetes. Conclusion: Secondary infrainguinal bypasses are associated with an increased rate of graft failure and significant limb loss, particularly in those with a history of rest pain or tissue loss, female gender, and early prior graft failure. More appropriate initial operations in carefully selected patients and aggressive postoperative graft surveillance is speculated to improve these outcomes.
A 15-Year Experience with Combined Vascular Reconstruction and Free Flap Transfer for Limb-Salvage
European Journal of Vascular and Endovascular Surgery, 2009
Objectives: To evaluate the results and complications of combined simultaneous arterial re-vascularisation and free flap transfer in patients with critical limb ischaemia and large soft-tissue defects that would otherwise have required major amputation. Design: Retrospective analysis of all combined procedures performed between 1993 and 2007 with regard to complications and outcome. Materials and methods: Seventy-eight procedures were performed in 76 patients with a mean age of 60 years (range: 18e80 years). The majority had diabetes (70.5%). Follow-up was obtained from hospital charts and telephone contacts with patients or GPs. Results: The limb-salvage rate was 93% after 1 year, 80% after 3 years and 71% after 5 years. Perioperative complications occurred in 50% of the patients; six out of 78 (7.7%) arterial reconstructions and 13 out of 78 (16.7%) flaps had to be revised during the early postoperative period. However, most flaps could be saved by a secondary procedure resulting in an early failure (amputation) rate of 6%. In-hospital mortality was 3.8%. End-stage renal disease was the only factor predicting limb loss. In total, 65% of the patients survived and were able to walk on their reconstructed limb at 1-year follow-up. Combined survival and limb-salvage rates were 85%, 66% and 51% after 1, 3 and 5 years. Conclusions: Combined arterial re-vascularisation and free flap transfer can be performed safely with acceptable morbidity and mortality and should be considered for every mobile patient with large soft-tissue deficit (>10 cm 2) without end-stage renal disease prior to major amputation.
Journal of Vascular Surgery, 2001
Overall survival in these patients has been consistently poor, which reflects their decreased life expectancy from multiple causes, including a high incidence of cardiac disease and infectious and access complications. 10-13 In addition, ESRD has a negative impact on morbidity, mortality, and survival after lower extremity amputation. 14 The risk/benefit ratio of infrainguinal arterial reconstruction for limb salvage in patients with chronic renal failure has thus not been clearly defined. The purpose of this retrospective review was to evaluate the perioperative and long-term results of patients with ESRD undergoing infrainguinal revascularization at a single institution. METHODS Patient population. A retrospective review was performed of all patients undergoing infrainguinal revascularization for limb salvage between December 1994 and December 1999. During this time period, 461 grafts were created in 425 limbs in 368 patients. Indications for operation included tissue loss (284 [62%]), rest pain (141 [30%]), and acute arterial ischemia (36 [8%]). Comorbid Improvements in the medical management of endstage renal disease (ESRD) have allowed more patients to survive for prolonged periods dependent on renal replacement therapy. The high incidence of atherosclerotic vascular disease in this population has led to an increased number of dialysis-dependent patients requiring arterial reconstruction for limb-threatening infrainguinal vascular disease. 1 Recent reports have documented graft patency 27
Free Vascularized Tissue Transfer for Limb Salvage in Peripheral Vascular Disease
Annals of Vascular Surgery, 1990
In patients with tissue necrosis, higher limb salvage rates can be accomplished with free tissue transfers performed by a vascular and plastic surgeon team. We treated 10 patients with severe ischemic soft tissue defects in their legs with radical debridement and free tissue transfer alone (two patients) or after revascularization (eight patients). Arteriography was performed to plan revascularization to evaluate bypass results, and to identify appropriate recipient vessels for free tissue transfer. Soft tissue defects treated with free tissue transfer included nonhealing amputation sites in five patients and proximal skin and muscle necrosis in the remaining patients, one of which resulted in an exposed in-situ graft in one leg. One patient underwent a distal bypass specifically to provide arterial inflow for free tissue transfer, whereas seven other patients received free tissue transfers following bypass due to persistently nonhealing wounds. The remaining two patients had diabetes mellitus with necrosis near a major joint with nonhealing amputation sites. Free tissue transfers were taken from the latissimus dorsi in six patients, and from the gracilis, rectus abdominis, rectus femoris, and scapula flaps in other patients. Recipient vessels for free tissue transfers were the external lilac artery (one patient), saphenous vein bypass grafts (two patients), popliteal artery (one patient), posterior tibial (three patients), and dorsalis pedis vessels (three patients). Eight of the 10 flaps were viable at follow-up (four months-six years), with a mean follow-up of 20 months. One patient underwent above-knee amputation 15 months after operation and one underwent below-knee amputation three years later due to central flap necrosis. The remainder achieved functional limb salvage allowing patients to resume ambulation. Vascular surgeons should consider free tissue transfer in patients with nonhealing soft tissue defects following optimal revascularization to further extend our ability to salvage the threatened limb.
Journal of Vascular Surgery, 2007
Background: A previous meta-analysis reported on the mid-term outcomes of infrainguinal bypass grafts in patients with critical limb ischemia and end-stage renal disease. Given the competing interest in endovascular procedures, the results of bypass surgery must be assessed as precisely as possible for future comparison. In this study, the original meta-analysis was refined and updated by increasing the number of studies reviewed, estimating primary graft patency, extending follow-up time, and investigating the problem of early amputation despite a patent graft. Methods: Studies published from 1987 through 2005 were identified from two electronic databases. Two investigators independently extracted the survival data from life tables, survival curves, and texts. Pooled survival curves were then constructed for graft patency, limb salvage, and patient survival according to a random-effects protocol for meta-analysis. Results: Of 28 articles included, 18 reported amputation despite a patent graft in 84 (10%) out of 844 limbs, and 25 described a perioperative mortality of 88 (8.8%) out of 996 patients. The 5-year pooled estimate (SE) was 50.4% (15.4%) for primary patency, 50.8% (19.0%) for secondary patency, 66.6% (11.2%) for limb salvage, and 23.0% (11.7%) for patient survival. No publication bias was detected. Conclusions: Limb salvage can be achieved in most end-stage renal disease patients who undergo bypass surgery for critical ischemia, but survival is poor. To avoid early amputation despite a patent graft, bypass grafting should not be offered to patients with a great amount of tissue loss or extensive infection. ( J Vasc Surg 2007;45:536-42.)
Journal of Vascular Surgery, 2004
A new look at outcomes after infrainguinal bypass surgery: Traditional reporting standards systematically underestimate the expenditure of effort required to attain limb salvage Background: Graft patency, limb salvage, and mortality are the traditional means of assessing the outcome of infrainguinal bypass surgery (IBS). However, these measures underestimate patient morbidity and fail to consider the entire spectrum of treatment required to restore the patients to their premorbid state. The aim of this study was to quantify the efforts required to achieve limb salvage by assessing three nontraditional outcomes: (1) index limb reoperation rate in 3 months, (2) hospital readmission rate in the first 6 months after IBS, and (3) wound-healing time. Methods: We retrospectively analyzed 318 IBSs performed at a single institution. Repeat operations for limb or graft-related problems and readmissions within 6 months of the initial operation were recorded. When available, wound-healing time was determined. Pertinent demographics and comorbidities were subjected to univariate and multivariate analysis to determine risk factors for adverse outcomes. Results: Seventy-two percent of patients underwent IBS for critical limb ischemia (CLI), and 84% had below-knee popliteal or distal bypasses. Among those who underwent IBS for CLI, 48.9% of patients required at least one reoperation within 3 months. Within 6 months, 49.3% of patients required hospital readmission. Time to heal exceeded 3 months in 54% of patients. After multivariate analysis, tissue loss and minority status were significant risk factors for reoperation within 3 months. Tissue loss and renal failure increased the odds for readmission within 6 months. Diabetes was the sole risk factor for prolonged wound healing.