VH8. Retrograde Angioplasty During a Transtibial Amputation

Abstract

The importance of the preservation of the knee joint for better rehabilitation of the vascular amputee is recognized but frequently underestimated. In the common practice of vascular surgery, all efforts are done for limb salvage, but this effort is mainly focused on foot preservation. When the foot is not salvageable, the level of amputation is mainly decided on ground of the perfusion status of the lower limb at the time of evaluation for the surgical procedure. The philosophy of revascularization for level preservation is proposed. Open or endovascular procedures should be done if it is understood that a patient considered for a transfemoral amputation may benefit from a transtibial amputation and the revascularization is feasible and the risk reasonable. The technique described is a procedure to enhance the healing capabilities of a transtibial amputation with marginal perfusion restoring absent popliteal pulse by means of a retrograde angioplasty done during the operation. The usual technique of a transtibial amputation is planned, with a long posterior flap that can be modified if necessary by skin necrosis extension or infection. The procedure goes anatomically through all leg compartments. After skin incision and deepening on surgical planes, section of anterior and peroneal muscles and vessels and nerves allow removal of a gap of peroneal bone and dissection of peroneal artery and vein. The tibia is then sectioned in a beveled fashion with a Gigli saw, from a posterior to anterior access, and then the posterior tibial nerve, vein, and artery are dissected. Specimen is removed, after treatment of sural nerve and vein. The posterior tibial artery is then approached, for the particular case described, and a retrograde angioplasty is done, by insertion of guide wires, catheters, and balloons as necessary. Angioplasty is performed and restoration of pulsatile flow at the area of the operative field documented.