Femorodistal Bypass Research Articles

Femorodistal bypasses using venous “cuffs”

Background/Aim. Although distal venous patch and cuff techniques are recommended to improve the patency of by-pass in the lower extremities, the advantage of these techniques remains unproven. Autovenous bypass graft remains the method of choice, but when there is no possibility of using the great saphenous vein, the venous cuff method may have an advantage. The aim of this study was to evaluate the results of femorodistal bypass procedures with a venous cuff in critical lower extremity ischemia. Methods. The study described the results of femorodistal bypass procedures after a follow-up period of 6 to 24 months. We followed 28 patients with distal composite anastomosis of femorodistal arterial reconstruction. Indications for surgical treatment were set on the basis of the clinical exam and morphological criteria based on multidetector computed tomographic angiography. Three types of distal graft-arterial anastomoses were applied: Miller?s cuff, Taylor?s patch, and St. Mary?s vein boot anastomosis. Results. After 6 months of surgery, all bypasses were passable; after one year, 2 (7%) patients had graft occlusion and above-knee amputation, and 8 (28%) patients died; after 24 months, 18 (64%) patients had primary bypass patency. Conclusion. Femorodistal bypass procedures using a synthetic graft and venous cuff have good long-term results. The optimal anastomosis type is St. Mary?s boot. A longer follow-up period and comparison with the autovenous bypass are necessary for a more detailed assessment of the final conclusion.

Virtual ankle-brachial index - Can we predict the immediate outcome of femorodistal bypass surgery?

Background/Aim. The best treatment for the occlusion of the largest artery in the thigh is a femorodistal (FD) bypass. Ankle-brachial index (ABI) and multidetector computed tomographic (MDCT) angiography are the gold standards for diagnosing peripheral arterial occlusive disease. The finite element analysis (FEA) method can help measure the quantity of blood flow and arterial pressure in the arteries in the leg. The aim of this study was to examine the possibility of using the FEA method in predicting the outcome of FD bypass surgery. Methods. The study involved 45 patients indicated for FD arterial reconstruction from December 1, 2021, to March 31, 2023. Each patient underwent pre- and postoperative MDCT angiography of the arteries of the lower extremities, on the basis of which, with the use of FEA, models were made for measuring ABI. All patients had their ABI measured pre-operatively and postoperatively using the Doppler ultrasound and sphygmomanometer. Based on the findings of the preoperative MDCT angiography, postoperative virtual surgical models were created using the FEA method, on which ABI were also measured. The values of ABI were divided into five groups: ABI measured preoperatively (ABI pre-op), ABI measured postoperatively (ABI post-op), ABI measured on FEA models based on the MDCT findings [ABI (sim) pre-op], ABI sim post-op, and ABI measured on virtual surgery model [ABI sim post-op (virtual)]. The ABI of the models were statistically compared with preoperative and postoperative measurements done on patients. Results. The values based on the virtual ABI model did not show significant differences compared to the values obtained on patients and values obtained with the FEA method using MDCT angiography (p < 0.001). A strong statistically significant correlation was shown between the virtual ABI and the values obtained by the other two methods, measured on the postoperative MDCT angiography model and virtual postoperative model (p < 0.001). Conclusion. Virtual simulation based on the MDCT angiography parameters of peripheral blood vessels can be successfully used to predict the immediate outcome of the FD bypass surgery.

Comparative Study between Femoro-distal Bypass Graft & Tibial Arteries Angioplasty in the Treatment of Critical Lower Limb Ischemia

Comparative Study between Femoro-distal Bypass Graft & Tibial Arteries Angioplasty in the Treatment of Critical Lower Limb Ischemia

Does the Mode of Anaesthesia (General or Regional) Affect Survival and Complications Following Femoropopliteal and Femorodistal Bypass?

Femoropopliteal and femorodistal bypasses are indicated in the management of severe claudication or critical limb ischaemia. The choice of type of anaesthesia between generalanaesthesia (GA) and regionalanaesthesia (RA; epidural/spinal) has remained controversial. The study aimed tocompare the rates of graft failure, perioperative mortality,and other major complications (including graft failure) associated with GA versus RA for lower limb bypass revascularisation in patients presenting with significant peripheral arterial disease. All patients who had femoropopliteal and femorodistal bypass at the vascular unit of Colchester Hospital between January 2016 and September 2018 were included. The primary outcome measure was survival, and secondary outcome measures were respiratory, wound, cardiac, and graft failure complications. Technical success was defined as asuccessful operation with demonstrated graft patency at discharge and up to 30 days of follow-up. Secondary outcome measures included respiratory, wound, and cardiac complications. Statistical analysis included descriptive statistics and tests of association using chi-square for graft failure outcomes and the Mann-Whitney U test for the length of stay. All analyses were done at a 5% level of significance. There were 139 patients identified during the study period who fulfilled the inclusion criteria, of which 127 had complete records. The overall mortality and morbidity in this study were 1.6% and 14.229%, respectively. The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018). A total of 65 patients received GA and 62 patients underwent RA; there were no significant differences in baseline preoperative comorbidities, postoperative mortality and complications, and length of stay. The majority (84%) of the patients who had RA had combined spinal and epidural (CSE) anaesthesia. The overall mortality and morbidity in this study were 1.6% and 14.2%, respectively. The proportion of patients with graft failure was 14.5% for GA versus 13.8% for RA (p = 0.914); there was no significant difference for conduit type, quality of vein conduit, the prevalence of heart failureand postoperative hypotensive episodes, redo-surgery, and major amputation, and length of stay (GA: 5.0, RA: 6.0, p = 0.854) did not differ significantly between the two groups.The proportion of patients who had ischaemic heart disease is almost threefold amongst those who had failed bypass compared to the successful bypass group (33.3% versus 11.9%, p = 0.018). The mode of anaesthesia, GA or the use of CSE RA in approximately half of the patients, did not influence survival, respiratory, cardiac, wound, graft failure, or length of stay in this study.There was a relationship between the presence of cardiac comorbidity and bypass failure, indicating a need for a standard care protocol to further optimise cardiac perioperative care to improve outcomes.

Early Graft, Limb and Mortality Outcomes from the Omniflow II Bio-Synthetic Graft

Omniflow II biosynthetic grafts are a commonly used alternative to autologous grafts in vascular bypass procedures. They are chosen for their purported resilience to infection, often in instances of existing graft failure or infection. We examined the short term, 1-3 year outcomes of Omniflow grafts in terms of patency, limb survival and mortality in a sample of 24 individuals. This is a single centred retrospective study of Omniflow II grafts implanted between September 23, 2015 and April 05, 2018 in our department. It includes grafts in all anatomical locations. Primary outcome measures were overall patient survival and time to this, primary graft patency (patency with no intervention) and then limb survival at 1 and 3 years. Kaplan-Meier survival analysis was plotted for the 3 primary outcome measures. A total of 24 grafts from 24 individuals were included with mean age 71.4 ± 11.7. We included 5 female and 19 male patients. The commonest indication was rest pain/claudication (N = 8) followed by graft occlusion (N = 6). Femoro-popliteal bypass (N = 13) and Femoro-distal bypass (N = 5) were the commonest procedures. Kaplan-Meier survival analysis demonstrated that 1 and 3-year primary patency rates were 54.2% and 37.5% respectively with Limb survival probability of 75% at 1 year and 70.8% at 3 years. These rates were all considerably lower than those found in previous comparative studies. Mortality however, compared favourably with 1 and 3-year survival probability 91.7% and 87.5% on average 296 days (range 95-451 days) after graft implantation. We found that rates of primary patency and limb salvage for this graft type were markedly lower than in comparable studies. Further work in the form of a RCT is indicated.

EVALUATION OF BALLOON ANGIOPLASTY IN INFRAPOPLITEAL INTERVENTIONS FOR PATIENTS WITH CRITICAL LIMB ISCHEMIA

Background: Peripheral arterial occlusive disease (PAOD) is a major disease that limits active aging in elderly people. Complications of PAOD are the leading cause of hospitalization and amputation for people with lower limb ischemia, and account for billion-dollar expenditures annually around the world. Objective: To assess the balloon dilation angioplasty in limb salvage rate and patency in infra-popliteal arterial occlusive disease. Patients and methods: This study was carried out as a prospective study, in Al-Azhar University Hospitals and 6 October HIO hospital on 20 diabetic patients with critical limb ischemia as defined by Rutherford classification, between Jan, 2019 and July, 2019. Written consents were obtained from all patients. Every patient received an explanation to the purpose of the study. Results: The present study was conducted on 20 diabetic patients, 11 males (55%) and 9 females (45%).Their ages ranged between 50 years and 87 years with a mean age of 66.7. Limb salvage was defined as freedom from major amputation, toe, ray, or trans-metatarsal amputations were considered as minor amputations. The limb salvage after 6 months was 70%, clinical successes were defined as relief of rest pain or improve healing of the ulcer and limb salvage, based on Rutherford categories. Of 3 patients (15 %) suffering from rest pain, Percutaneous Transluminal Angioplasty (PTA) succeeded in 2 patients (66.7%) and became non-disabling cludicants at more than 400m. PTA failed in one patient (33.3%), who underwent redo angioplasty, but failed again. He received conservative treatment in the form of anticoagulants, antiplatelets and vasodilators without improvement and ended by major amputation. Of 17 patients (85 %) suffering from minor tissue loss, PTA succeeded in 11 patients (64.7%) improve healing was achieved, PTA failed in 6 patients (35.3%) four patients underwent femoro-distal bypass surgery, but failed and diabetic foot infection with osteomyelitis reached up to ankle joint and ended by major amputation. Two patients underwent above knee amputation before six months. Two patients underwent below knee amputation at six months. The other 2 patients underwent above knee amputation before six months due their deterioration of their general condition. Conclusion: Tibial angioplasty demonstrated its feasibility, safety and effectiveness in the treatment of diabetic patients with CLI.

Outcomes of biosynthetic vascular graft for infrainguinal femoro-popliteal and femoro-distal revascularization.

The aim of this study was to retrospectively analyze early and late outcomes of infrainguinal revascularization performed with the Omniflow-II® (LeMaitre Vascular, Inc., Burlington, MA, USA) biosynthetic vascular graft (BVG) for complex femoro-popliteal obstructive disease. Over a 10-year period, this BVG was used in 110 patients who underwent infrainguinal femoro-popliteal or femoro-distal bypass. Early (intraoperative and <30 days) results were analyzed in terms of death, thrombosis, amputations and reinterventions. Follow-up results were analyzed in terms of primary and secondary graft patency, and amputation-free survival. We performed 87 (79.1%) above-the-knee bypass, 20 (18.2%) below-the-knee bypass, and 3 (2.7%) tibial artery bypass. In-hospital mortality was not observed. Mean follow-up was 66±37 months (range, 3-150). Estimated primary patency rate at 1, 2 and 5-years of follow-up was 77%±4 (95%CI: 68-84), 73%±5 (95%CI: 63.5-83), and 59%±6 (95%CI: 47-70.5) respectively. Predictors of primary patency loss were the presence of critical limb ischemia (P=0.048; HR: 2.1; 95%CI: 1.01-4.28), and the necessity of below-the-knee bypass (P=0.012; HR: 2.4; 95%CI: 1.22-4.75). Aneurysmal degeneration of the BVG was detected in 4 (3.6%) patients, an infected BVG occurred in 3 (2.7%) patients. The amputation-free survival was 96%±2 (95%CI: 91-99), 93%±3 (95%CI: 86-96), and 76%±5 (95%CI: 66-84) at 1, 2 and 5-years respectively. In our experience, Omniflow-II® is a valid first-line alternative for infrainguinal revascularization when the ipsilateral autologous saphenous vein is not available. Aneurysmal degeneration was lower than previously reported with alternative BVGs, and the incidence of BVG infection was acceptably low.

Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan–Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p = .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p = .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p = .002, p = .003, and p = .018, respectively), with no difference between DR and IR. Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Chronic Limb Threatening Ischaemia

In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whethertargeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan-Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p=.071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p=.088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p=.002, p=.003, and p=.018, respectively), with no difference between DR and IR. Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

Revascularization in Mönckeberg medial calcific sclerosis

Mönckeberg medial calcific sclerosis (MMS) is a rare disorder of medial calcification for which open repair has always been the standard. We present two unusual cases of MMS affecting different arterial segments, for which bypass was done. The first patient presented with extensive aortoiliac medial calcification. She had a near normal ankle brachial index on one side and critical limb ischemia on the other. A femorofemoral crossover bypass was carried out. The patient improved symptomatically. The second case involved a femoropopliteal segment Mönckeberg sclerosis for which a femoro-distal bypass was carried out. Both patients continue to remain asymptomatic after 2 years of follow-up. Open surgical repair remains the ideal method of repair in this rare condition of medial calcific sclerosis. The disease progression is very slow in these patients, and usually one segment of artery is involved.

Comparative study of outcomes between single-vessel versus multiple-vessel infrapopliteal angioplasties in patients with chronic limb-threatening ischemia

Purpose: To determine whether the number of infrapopliteal arteries undergoing endovascular treatment is associated with the limb salvage and wound healing in patients with chronic limb-threatening ischemia (CLTI). Materials and Methods: This was a single-center, prospective, nonrandomized study comprising 143 CLTI patients who underwent successful infrapopliteal angioplasty without or corrected inflow femoropopliteal disease, at Jain Institute of Vascular Sciences, Bengaluru, between May 2017 and October 2018. Patients were divided into two groups, based on either a single vessel (SV group, n=91) or a multiple infrapopliteal vessels (MV group, n =52) were angioplastied. Patients with isolated femoropopliteal revascularization, femorodistal bypass, prior vascular intervention, technical failure, and lost to follow-up were excluded. Primary outcomes were limb salvage and wound healing at 6th month. Secondary outcomes were changes in ankle–brachial index (ABI), toe–brachial index (TBI), transcutaneous oxygen saturation (TcPO2), plantar arch quality (PAQ), major adverse cardiac events (MACE), and all-cause mortality at 6th month. Results: Baseline characteristics were comparable in both groups. The wound healing rate (70.12% vs. 62.79%) and limb salvage rate (93.51% vs. 90.70%) at 6th month were comparable among SV and MV groups (P = 0.88 and 0.59, respectively). The mean wound healing time was significantly better in MV group (83 ± 40 vs. 108 ± 43 days) (P = 0.003). MACE (6.59% vs. 9.80%), mortality (15.38% vs. 17.30%), PAQ [complete (31.87% vs. 36.54%), incomplete (48.35% vs. 57.69% ) and absent arch (19.78% vs. 5.76%) in SV and MV groups, respectively], and changes in ABI, TBI, and TcPO2among both groups were comparable, except TcPO2changes at 1 month which showed a significant improvement in MV group (P = 0.03). Conclusions: MV infrapopliteal angioplasties are associated with shorter wound healing time, but have no effect on limb salvage and wound healing rates at 6th month.

Analysis of the Haemodynamic Factors Involved in Neointimal Hyperplasia Growth in Femoro-Popliteal Bypass Grafts Using Different Multi-scale, Patient-specific Modelling Approaches

Introduction: Neointimal hyperplasia (NIH) is a major obstacle to the long term patency of peripheral vascular grafts. The disease has a complex aetiology which is influenced, among other phenomena, by mechanical forces such as shear stresses acting on the arterial wall. Objectives: The aim of this work is to assess the impact of haemodynamic factors in a patient-specific, multi-scale modelling framework developed using computational fluid dynamics (CFD) and mathematical biology, for the quantification of NIH growth. Methods: Simulations were performed on datasets from two femoro-popliteal and one femoro-distal bypass patients. Patient data (imaging and haemodynamics) was obtained from Yale University School of Medicine. In this work, smooth muscle cells and collagen in the vascular tissue were modelled using ordinary differential equations. These were linked to wall shear stress (computed using CFD) through its relationship with nitric oxide and growth factors. Results: Results obtained by simulating the growth via the combined CFD and mathematical biology framework seems to outperform analyses performed with haemodynamic indices (obtained by CFD) alone, enabling to pinpoint the locations of NIH and to achieve quantification of its growth. For instance, when only accounting for the time-averaged wall shear stress in the rigid wall model, luminal narrowing was underestimated by up to 19.3%, while when also accounting for oscillatory behaviour the model was able to reach the amount of occlusion present (as measured in the CT scans), with an average overestimate of 10%. Conclusion: The study presents a patient-specific, multiscale simulation framework to model NIH progression. While a previous version of the model underestimated the occlusion of the lumen due to NIH, the results presented show an improvement in estimating occlusion by accounting for movement of the arterial wall, oscillatory behaviour of shear stress and non-Newtonian properties of blood viscosity.

Inflammation and myointimal hyperplasia. Correlation with hemodynamic forces

ObjectivesThe aim of our study was to correlate flow dynamics and the release of inflammatory cytokines Interleukin 1, 2, 6, TNF (Tumour Necrosis Factor) alfa, both in vitro and in vivo. Materials and methodsEndothelial cells were exposed to laminar flow (6dyne/cm2) in an in vitro circulatory system and the release of Interleukin 1, 2, 6 and TNF alfa was quantified by ELISA. Interleukin 1, 2, 6 and TNF alfa release was also assessed in vein grafts implanted in the arterial circulation of Lewis rats. Arterial vein grafts were explanted at different time intervals from 3days to 12weeks after surgery. Vein grafts implanted in the arterial circulation for 4weeks, were re implanted in the venous circulation of syngenic Lewis rats, and the release of Interleukin 1, 2, 6 and TNF alfa, was assessed in an organ culture.Six vein grafts (4 occluded, 2 patent) implanted in humans as femorodistal bypass were examined for the presence of myointimal hyperplasia and perigraft inflammatory cells. ResultsIn vitro, endothelial cells exposed to laminar flow released an increased amount of Interleukin 1, 2, 6 and TNF alfa in comparison to endothelial cells not exposed to flow.In experimental vein grafts implanted in the arterial circulation there was an increased release of inflammatory cytokines associated to inflammatory changes in the adventitia. Once the vein grafts were re implanted in the venous circulation, the release of these cytokines diminished, while the inflammatory changes in the adventitia regressed. ConclusionsIncreased shear stress induces release of cytokines and inflammatory changes in the adventitia. These inflammatory changes can contribute to plaque progression and to un stable plaque. These findings support the use of anti-inflammatory therapy in patients prone to develop atherosclerosis and in those who had arterial reconstructive surgery.

Patient-Specific, Multi-Scale Modeling of Neointimal Hyperplasia in Vein Grafts.

Neointimal hyperplasia is amongst the major causes of failure of bypass grafts. The disease progression varies from patient to patient due to a range of different factors. In this paper, a mathematical model will be used to understand neointimal hyperplasia in individual patients, combining information from biological experiments and patient-specific data to analyze some aspects of the disease, particularly with regard to mechanical stimuli due to shear stresses on the vessel wall. By combining a biochemical model of cell growth and a patient-specific computational fluid dynamics analysis of blood flow in the lumen, remodeling of the blood vessel is studied by means of a novel computational framework. The framework was used to analyze two vein graft bypasses from one patient: a femoro-popliteal and a femoro-distal bypass. The remodeling of the vessel wall and analysis of the flow for each case was then compared to clinical data and discussed as a potential tool for a better understanding of the disease. Simulation results from this first computational approach showed an overall agreement on the locations of hyperplasia in these patients and demonstrated the potential of using new integrative modeling tools to understand disease progression.

Anomalous origin of posterior tibial artery from anterior tibial artery: beware!

A 64 year old diabetic, hypertensive male with claudication and rest pain in his left leg was found to have diffuse narrowing below the politeal artery in the left lower limb with good collaterals. There was bifurcation of the right popliteal artery above the knee joint and an anomalous origin of the right posterior tibial artery from the anterior tibial artery. Awareness of anotomical variations is important for evaluation of the lower extremity arteriograms, for vascular surgeons during reconstructions such as femorodistal bypass graft procedures and embolectomy, during surgical techniques such as arthroscopy, tibial osteotomy, vascular reconstruction grafts, plastic surgical flaps and catheterization procedures.

Critical Limb Ischemia Complicated by Essential Thrombocythemia Treated with Femorodistal Bypass

Critical Limb Ischemia Complicated by Essential Thrombocythemia Treated with Femorodistal Bypass

Efecto terapéutico del alprostadil en pacientes con isquemia crítica terminal de los miembros inferiores

ObjetiveManagement of critical lower limb ischemia represents a challenge for the vascular surgeon due to the high rate of amputations and mortality. Current management options include femorodistal bypass, angioplasty with or without stent and laser or mechanical resection of the plaque. They present a low success rate in the long run and a number of supracondylar amputations that still remains high. MethodsThis prospective study included 173 patients diagnosed with advanced stage critical lower limb ischemia who were treated with systemic intravenous alprostadil (60 - 120 mcg/day) during 8 days. Response was measured clinically with improvement of capillary refill and using the visual analog scale for pain. ResultsUpon discharge 94.3% of patients improved their visual analogue scale score for pain (p < 0.0001). Follow-up for more than a year of alprostadil treatment revealed that 97% of patients significantly improved their ischemia status, thus avoiding further amputation. No response to treatment was observed in patients who had previously undergone endovascular surgery (5 patients). ConclusionsTreating patients with critical lower limb ischemia with intravenous alprostadil, administering daily doses of between 60 and 120 mcg during 28 days shows that this drug is safe and causes minimal secondary effects. This therapy significantly improves Rutherford's function state in these patients and avoids further amputations.

Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Critical Limb Ischemia.

Impact of Angiosome Targeted Femorodistal Bypass Surgery on Healing Rate and Outcome in Critical Limb Ischemia.

Prognostic Significance of Different Strategies of Angiosome Targeted Lower Limb Revascularization

Prognostic Significance of Different Strategies of Angiosome Targeted Lower Limb Revascularization

Validation of the Guy's scoring system in patient selection for femoro-distal bypass grafting to a single calf or pedal artery.

First external validation of a preoperative scoring system (Guy's) in patient selection for femoro-distal bypass grafting to single calf or pedal artery in critical limb ischemia (Fontaine III & IV/Rutherford grade IV, V & VI). A prospective study of 76 (n = 76) consecutive femoro-crural/pedal bypass grafts on 72 individuals (n = 72) from 2008 to 2011 with 36 months mean follow-up was performed. All cases were scored against a previously designed and published scoring system (ranging from 0 to 10) based on: inflow, outflow, graft material, flow type, patent pedal vessels and diabetes mellitus. Preoperative score of 0-4 (n = 37) demonstrated the primary patency of 27% at 10.3 months. This value for intermediate group 5-7 (n = 34) was 70.6% at 18.9 months. The high-score group 8-10 (n = 4) showed the longest primary patency (80%) at 27.3 months. Kaplan-Meier survival analysis exhibited a consistent and significant difference in primary assisted, secondary patency and overall limb/foot salvage amongst all individual scoring groups (p < 0.001). This study validates and complements the Guy's scoring system and provides a platform for the identification of critical limb ischemia patients in whom the result of femoro-crural/distal bypass grafting is so poor that primary amputation may be both clinically and economically more justified.