Arterial reconstruction of vessels in the foot and ankle.

Abstract

This study demonstrated that arterial reconstruction of vessels of the foot and ankle can preserve the majority of ischemic extremities with extensive tibial and peroneal occlusive disease and patent pedal arteries. There are successful reports of bypass procedures to the ankle and foot, but despite this, these procedures have not gained widespread acceptance among surgeons performing infra-inguinal revascularization. Primary amputation is often offered for such patients. For this reason, the authors have reviewed their experience with bypasses to the foot and ankle. A retrospective review was done of 75 arterial bypasses (5 bilateral), done since 1985, to the ankle and foot in 70 patients (38 males and 32 females). Fifty-four (77%) of the patients were diabetic. The age ranged from 55 to 95 years. Twenty-six (37%) were older than 80 years. The patients were selected for operative intervention because of severe tibioperoneal occlusive disease with ischemic rest pain or gangrene of the foot. Digital subtraction arteriography facilitated visualization of distal vessels. Operative principles included regional anesthesia, autogenous graft material, short bypass, non-traumatic vessel occlusion, selective operative arteriography, tension free ankle and foot skin closure, and concomitant conservative debridement of infected devitalized tissue. Incomplete pedal arch did not influence decision for operation. Indications for operation were: gangrene, 42 (56%); non-healing ulcer, 21 (28%); and rest pain, 12 (16%). Graft material was in situ greater saphenous vein, 40 (53%); translocated greater saphenous vein, 19 (25%); reversed greater saphenous vein, 11 (15%); and arm vein, lesser saphenous vein or vein patch, 5 (7%). Donor artery was popliteal, 30 (41%); common femoral, 26 (35%); and superficial femoral, 17 (23%). Recipient vessel was dorsalis pedis, 43 (57%); posterior tibial, 18 (24%); distal anterior tibial, 9 (12%); and distal peroneal, plantar or tibial endarterectomy, 5 (7%). There were four (5.7%) deaths and three (4.2%) graft failures within 30 days. Early graft failure led to transmetatarsal amputation (1), below knee amputation (1), and conversion of graft to femoral (1), popliteal bypass graft with limb salvage (1). In one patient, significant tissue necrosis with infection necessitated a below knee amputation within 30 days, despite a patent graft. Long-term follow-up revealed 10 graft failures, 4 major amputations, 3 graft revisions, and 15 deaths. Cumulative primary and secondary patency was 79.0% and 81.6% at 36 months. Limb salvage was 87.5% at 36 months. These results support an aggressive approach to limb salvage in patients with threatened limb loss, unreconstructable tibio-peroneal occlusive disease, and patent pedal arteries. Bypasses to the ankle and foot will maintain a functional extremity in the majority of these patients.