Intraoperative prebypass arteriography for infrageniculate revascularization

Abstract

Selection of the optimal distal target for infrageniculate arterial revascularization remains difficult in patients with multilevel occlusive disease due to poor visualization of the distal vasculature by preoperative arteriography. Prebypass, intraoperative arteriography (IOA) with direct injection of contrast into the infrageniculate arteries may improve distal arterial visualization and bypass target selection. One hundred fourteen extremities in 104 consecutive patients requiring infrageniculate bypass were prospectively studied. All patients underwent preoperative contrast arteriography (CA) of the aortoiliac and lower extremity arteries using iodinated and/or CO2 contrast and digital subtraction techniques. IOAs were obtained at operation to confirm the adequacy of the distal runoff from the predicted bypass target and to identify potentially superior targets. The preoperative plan formulated from the CA was compared to the actual procedure performed based on the IOA. The CA and IOA were also independently reviewed postoperatively by two blinded vascular surgeons to determine the number of patent vessel segments visualized and the number of segments with <50% stenosis. Revascularization was done in 105 of 114 extremities (92%), whereas amputation was required as the initial procedure in 9 patients (8%). The IOA altered the operative plan based on the CA in 27 of 144 patients (24%). Changes in the planned bypass procedures included selection of a more distal anastomotic site in 13 of 102 patients (13%), selection of a more proximal anastomotic site in 4 of 102 (4%), selection of a different artery for the distal anastomosis in 3 of 102 (3%), and amputation rather than bypass in 2 of 102 patients (2%) with no suitable distal bypass target on the IOA. The IOA also resulted in bypass rather than planned amputation in 5 of 12 patients (42%) deemed unreconstructable on the preoperative CA. A mean of 13 minutes was required for IOA and an adequate study was obtained on the first attempt in 98 of 144 patients (86%). On postoperative review, more patent vessel segments but fewer segments with <50% stenosis were identified on the IOA compared to the CA. Prebypass intraoperative arteriography facilitates selection of the optimal distal bypass target during infrageniculate revascularization and can result in initial limb salvage in select patients deemed unreconstructable by preoperative contrast arteriography.