Results of in situ femoropopliteal (tibial) bypass in patients with extended lower limbs arterial bed lesion and critical ischemia

Abstract

Aim. To specify the indications for in situ femoropopliteal (tibial) bypass, to study complications rate immediately after, within 1 and 2 years of the surgery.
 Methods. The study group included 33 patients with symptoms of critical lower limb ischemia, who underwent femoral-popliteal or femoral-tibial bypass. 4 (12.1%) cases of type C and 29 (87.9%) cases of type D arterial bed lesions according to TASC II classification were revealed after investigation. Patients were followed up for 2 years period. Shunt thrombosis rate, condition of the trophic ulcers, chronic arterial ischemia stage before and after the surgery, mortality, lower limb amputation were measured outcomes.
 Results. Repeated reconstructions rate for primary shunt thrombosis immediately after surgery was 30.3±8.0%. Shunt thrombosis (secondary) occurred in only three (9.1±5.0%) patients. The main causes which led to the shunt thrombosis during or at the 1st day after the surgery, were absence of intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries. Trophic defects healing was observed in 3 (30.0±14.5%) of 10 patients with ulcers immediately after surgery and in all cases (100.0%) by the end of 1 year follow-up. The total number of high-level amputations within 2 years was 25.8±7.9%, the overall mortality rate within 2 years was 6.1±4.2%. Femoral-popliteal or femoral-tibial bypass surgery allowed to preserve the limb in 74.2% of patients within 2 years of follow-up. Bypass patency was preserved in 41.7% of patients out of 24 in situ bypass surgeries for the follow-up time. In our opinion critical limb ischemia with significant and extended arterial bed lesions of D and C types (according to TASC II score) is one of the indications for in situ femoropopliteal (tibial) bypass as for the surgery of the first choice. Endovascular treatment is also impossible for this type of lesion, as alternative surgeries using reversed autovein and synthetic explant do not meet all the requirements for an extended bypass.
 Conclusion. The lack of adequate intraoperative valvulotomy quality control and presence of unligated great saphenous vein tributaries may be the causes of early postoperative shunt thrombosis; despite the low femoropopliteal (tibial) bypass patency rate in patients with critical ischemia, the surgery was recognized as efficient as it allowed to preserve the limbs in 74.2% of patients.