Pedal Bypass for Limb Salvage

Abstract

Background: Pedal bypass grafting is often the only method of limb salvage in patients with chronic critical lower limb ischemia due to atherosclerotic obliteration of the crural arteries, including patients with diabetic foot gangrene. It involves arterial reconstruction with distal anastomosis to one of the pedal arteries.Material and Methods: Between January 2000 and June 2004, 54 pedal bypasses were performed in 53 patients with chronic critical lower limb ischemia. Forty-seven (87%) patients had gangrene or ischemic ulcer, 36 (68%) had diabetes. In some of the patients (16.7%), previous percutaneous transluminal angioplasty (PTA) of the crural arteries had failed. Preoperative angiographic findings were unsatisfactory in the majority of the patients; the plantar arch was not visualized in 36 (66.7%) limbs.Results: In the period investigated (54 months) 11 grafts (20.4%) failed. Early thrombectomy resulting in long-term graft patency salvaged five limbs. One limb with graft occlusion occurring after foot ulcer healing was also salvaged. However, one amputation had to be performed despite a patent graft. The perioperative mortality rate was 3.8%. Cumulative primary and secondary graft patency rates and limb-salvage rates at 54 months were 76%, 78% and 81%, respectively.Conclusion: Pedal bypass grafting is a safe method with very good long-term outcomes. The absence of the pedal arteries or plantar arch on preoperative angiograms need not be taken as a contraindication to pedal vascular reconstruction. In discussions on the plantar arch it is recommended to discriminate between its actual absence and a mere “angiographic” absence.