Radial artery flow-through graft: A new conduit for limb salvage (original) (raw)
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Journal of Vascular Surgery, 1988
Secondary vascular procedures m below-knee vessels for lower extremity ischemia present a challenge to the vascular surgeon. Autogenous vein is often unavailable and failure of the previous bypass often limits the choice of distal vessels suitable for revascularization. This dilemma raises the question of amputation vs secondary vascular surgery. To address this question we reviewed the results of our previous aggressive approach to revascularization in a select group of 25 patients (26 limbs) who had secondary procedures with polytetrafluoroethylene grafts to tibial vessels or the infragenicular popliteal artery with singlewessel runoff. Nine of these 26 bypasses (35%) have remained patent for a mean of 17.2 months and no amputations have been done in this group. The other 17 bypasses (65%) have occluded from I day to 36 months postoperatively (mean 4.3 months); 15 of these limbs have required major amputation (58%). Ten were performed within the first 3 months postoperatively. Thirteen of the 25 patients died in the follow-up period (mean 27.5 months); five of these patients had viable limbs. Of 12 surviving patients (mean follow-up 19.9 months), six had viable limbs and six have required amputation. These results indicate that patients having secondary vascular surgical procedures with polytetrafluoroethylene grafts to tibial vessels have a high amputation rate and poor overall survival. Within this select group Of patients, those who could walk with the aid of a prosthesis should be considered as candidates for primary amputation. This would facilitate rehabilitation and avoid the anguish of recurrent graft failure and multiple procedures. (J VAsc SURG 1988;8:137-42.) Failure of a previously constructed femoropopliteal or femorotibial bypass constitutes a problem frequently seen in vascular surgery. 1-3 With failure of the primary grafting procedure most patients return to their preoperative status or deteriorate, thereby facing limb loss. These patients will require a secondary procedure, either thrombectomy, revascularization, or amputation. Secondary bypasses are nearly always below the knee, often have limited singlevessel rtmoff, and usually require the use of prosthetic material. The initial failure suggests these patients have inherent factors working to limit the success From the
Preservation of the Ischemic Leg by Distal Vascular Bypass
Annals of Surgery, 1977
Autogenous saphenous vein bypass grafts to tibial or peroneal vessels have resulted in successful, long-term limb preservation in appropriately selected patients. This success appears to justify an aggressive approach to what has previously been considered "end-stage" distal vascular occlusive disease. This report describes the clinical management and long-term follow-up of 41 patients with tibial artery reconstruction.
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.
Journal of Vascular Surgery, 2015
Objective: Combined vascular reconstruction and free flap transfer has been established in centers as a feasible therapeutic option in cases with critical limb ischemia (CLI) and large tissue defects otherwise destined for major amputation. However, the number of patients treated with this combined approach is limited, and data regarding long-term follow-up and functional outcome are scarce. We therefore report our 10-year experience in free flap transplantation after vascular reconstruction as a last attempt for limb salvage, with special emphasis of complication rate, limb salvage, and postoperative mobility. Methods: CLI patients undergoing combined vascular reconstruction and consequent free flap transfer from 2003 to 2013 were retrospectively observed. Of 80 cases in total, patients with traumatic and oncologic indications were excluded; 33 (mean age, 66 years; range, 51-82 years) of these cases were performed for limb salvage and were included in this study. Long-term follow-up was possible in 32 of 33 patients (mean, 58 months; range, 2-126 months). Results: Thirty-three patients were analyzed. We performed arterial revascularization with 9 arteriovenous loops, 23 bypass grafts (10 popliteal-pedal, 9 femoral-crural, and 4 femoral-popliteal), and 1 venous interposition graft. For defect coverage, tissue transfer was comprised of six different flap entities (10 latissimus dorsi, 2 gracilis, 1 anterior lateral thigh, 7 rectus abdominis, 11 radialis, and 2 greater omentum flaps). Complications occurred in 16 of 33 patients (49%). Early complications included eight acute occlusions of arterial reconstructions; major bleedings were seen in eight patients as well. There were two flap losses and one major amputation in the early postoperative period. No in-hospital deaths were observed. Late results revealed a limb salvage rate of 87% after 1 year and 83% after 5 years. Amputation-free survival was 87% after 1 year and 75% after 5 years. Overall survival was 100% and 87% after 1 year and 5 years, respectively. Follow-up showed 42% of patients with no limitations in ambulation, 54% with maintained preoperative ambulatory status, and one bedridden patient. Conclusions: The combined approach for limb salvage in CLI patients is associated with excellent results in limb salvage and functional outcome in patients who would otherwise be candidates for major amputation, despite an initially elevated complication rate. The option of combined revascularization with free tissue transfer should be evaluated in all mobile patients with CLI, large tissue defects, and exposed tendon or bone structures before major amputation. However, further studies are required to support these results.
Prosthetic vascular graft management in above-knee amputations
Cardiovascular journal of Africa, 2022
OBJECTIVE Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level. METHODS Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients ( n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared. RESULTS Differences in growth of wound culture (...
Journal of Vascular Surgery, 1997
We report the case of a 71-year-old man who had interval gangrene of his calf with subsequent vein graft blowout 3 months after undergoing a femoral-to-dorsalis pedis saphenous vein bypass grafting procedure. To provide wound coverage, restore vascular continuity, and preserve functional ambulation, a flow-through radial forearm fasciocutaneous free flap was interposed between cut ends of the bypass graft. Venous drainage of the flap was from the cephalic vein to the popliteal vein. At 1 month after the operation, the patient had complete wound healing and began to ambulate. At 11 months an asymptomatic high-grade stenosis in the distal radial artery segment of the reconstruction was successfully treated with percutaneous angioplasty. After 22 months of follow-up there have been no further complications, and the patient continues to have full, functional ambulation. The radial forearm flow-through free flap allows single-stage restoration of bypass graft continuity and coverage of extensive, complex tissue defects. This technique represents a novel approach to this difficult problem and provides a viable alternative to major limb amputation. (J Vase Surg 1997;26:711-4.) Free tissue transfer as an adjunct to vascular reconstruction is proving a successfifl alternative to amputation in patients who have critical lower ext r e m i t y ischemia and extensive tissue loss. Several small series report l i m b salvage rates between 70% and 90% at more than 2 years of follow-up. ~ s Interval gangrene, or segmental ischemic tissue necrosis despite a patent bypass graft, is an even greater obstacle t o limb salvage. O f eight patients reported over the past 20 years, six required major amputation and two were treated with latissimus dorsi free tissue transfer. 6-1° We describe a case of aggressive limb salvage and wound coverage using a radial forearm fasciocutaneous flow-through free flap in an elderly, diabetic patient who had femoropedal bypass graft blowout as a result of interval gangrene. Although flow-through radial forearm free flaps have been used in traumatized limbs and radical excisions of head and neck tumors, t~,12 we believe this report represents the first application of this technique to limb salvage in the setting of interval gangrene and vein graft rupture.
Journal of Vascular Surgery, 2012
Objective: Endoscopic vein harvest (EVH) has been demonstrated to improve early morbidity when compared with conventional open vein harvest (OVH) technique for infrainguinal bypass surgery. However, recent literature suggests conflicting results regarding mid-and long-term patency with EVH. The purpose of this study is to compare graft patency between harvest techniques specifically in patients with critical limb ischemia. Methods: This retrospective study compared two groups of patients (EVH [ 39 and OVH [ 49) undergoing lower extremity revascularization from January 2009 to December 2011. Outcome measures included patency rates, postoperative complications, and wound infection. Graft patency was assessed using Kaplan-Meier curves. Results: Both groups were matched for demographics and indications for bypass (critical limb ischemia). Median follow-up was 22 months. There was a significant reduction in the incidence of wound infection at the vein harvest site in the EVH group (OVH [ 20%; EVH [ 0%; P < .001), nevertheless, the difference was not significant when only the anastomotic sites were included (OVH [ 12.2%; EVH [ 15.4%; P [ .43). The hospital length of stay was comparable between the two groups (EVH [ 8.73 6 9.69; OVH [ 6.35 6 3.28; P [ .26) with no significant difference in the recovery time. Primary graft patency rate was 43.2% in the EVH group and 69.4% in the OVH group (P [ .007) at 3 years. The most common reason for loss of primary patency was graft occlusion (61.5%) in the OVH group and vein graft stenosis (54.5%) in the EVH group. The average number of vascular reinterventions per bypass graft was significantly lower in the OVH group compared with the EVH group (OVH [ 0.37; EVH [ 1.28; P < .001). Conclusions: Our findings demonstrate inferior primary patency when using the technique of EVH. Additionally, we identified a significantly higher rate of reintervention in the EVH cohort as well as a higher rate of vein graft body stenosis. However, EVH was associated with a decreased rate of wound complications with similar limb salvage and secondary patency rates when compared to OVH. EVH should therefore be selectively utilized in patients at high risk for wound complications.
Journal of Vascular Surgery, 2006
This study examined the hypothesis that superficial femoral artery (SFA) subintimal angioplasty (SI-PTA) can maintain limb salvage with minimal complications in patients with symptomatic occlusive arterial disease. Methods: From March 1, 2004, until April 28, 2006, 78 patients with rest pain (62.2%), gangrene (25.6%), or severe progressive claudication (12.2%) were treated consecutively with 82 SFA SI-PTAs (4 bilateral). The mean age was 59 ؎ 1.2 years, and 21 (27%) of the patients were female. All patients were treated in the operating room under local anesthesia by using fluoroscopic guidance, and the percentage SFA that was occluded was measured during the diagnostic portion of the procedure. Selective stent placement was performed after successful recanalization of the occluded arterial segments. Patients were treated with chronic aspirin and clopidogrel bisulfate for 3 months and followed up at 30 days and then every 3 months with physical examination and arterial duplex scan. Results: Of the 82 SFA SI-PTA attempts, 76 (92%) were initially successful, with an increase in the ankle-brachial index from 0.46 ؎ 0.02 to 0.88 ؎ 0.01 (P < .001). Five of the six patients with a failed SFA SI-PTA were female, two of the six had had previous bypass attempts, and one of the six had had a previous SFA SI-PTA attempt by another physician. Forty-nine (64%) of the 76 initially successful SFA SI-PTAs required placement of a stent, and 43 (56.5%) of the successful 76 SFA SI-PTAs required additional PTA of 1 or more arterial segments. The group treated with a successful SFA SI-PTA had 42.5% ؎ 3.5% SFA occlusion, compared with 82% ؎ 10% (P < .05) in the group with a failed attempt at SFA SI-PTA. Two of the six patients with initial SI-PTA failure underwent leg amputation within 30 days, three were treated with successful leg bypass surgery, and one was lost to follow-up. Of the 76 successful SFA SI-PTAs, 5 (6.5%) failed within 90 days, and the patients were treated successfully with leg bypass surgery. Of the 71 limbs with patent SI-PTAs at 90 days, 68 have remained patent with a mean follow-up 10.4 ؎ 0.7 months (range, 2-24 months). Three of the 71 SFA SI-PTAs failed between 4 and 7 months (mean, 5 ؎ 0.7 months): 1 patient was treated with successful bypass surgery, 1 patient is currently considering further intervention, and 1 patient was treated with amputation. Ten (14%) of the 71 successful SFA SI-PTAs required limited PTA for asymptomatic restenosis, as identified by the arterial duplex scan (7.4 ؎ 1.4 months; range, 2-16 months). There were no perioperative deaths, and three patients have died during follow-up with patent SFA SI-PTAs (9.3 ؎ 1.4 months). Conclusions: These data suggest that SFA SI-PTA can be successfully used for limb salvage with minimal morbidity and mortality in a group of patients with severe lower extremity occlusive vascular disease.
Journal of Vascular Surgery, 1995
Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability. Methods: We reviewed our experience over an 8-year period in 367 consecutive patients undergoing 384 vein bypass grafts to the dorsalis pedis for limb salvage. Results: Ninety-five percent of the patients had diabetes mellitus. Infection complicated ischemia at initial presentation in 55.2% of patients. The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent exploration for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasses were carried out in 357 of 362 cases, where preoperative arteriography demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 1i of 12 patients where angiographic status was unknown. All procedures were performed with vein: in situ 38.5%, reversed 29%, nonreversed 18%, arm vein 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a previously placed graft in 5%, and a tibial artery in 1%. There were seven perioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Twenty-nine grafts failed within 30 days (7.5%), but 19 were successfully revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional major amputations. Actuarial primary and secondary patency and limb salvage rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts. Conclusions: Dorsalis pedis arterial bypass is an effective limb salvage procedure with 10ng-term durability comparable to distal vein grafts placed into more proximal arteries.