Salvage Of Extremities Research Articles

Do scoring scales work for determining salvage of extremities with severe trauma?

Do scoring scales work for determining salvage of extremities with severe trauma?

Emergency and delayed microsurgical salvage of traumatic lower extremities

Background/Aim: The power of free flaps for lower extremity injury reconstruction is no longer a matter of debate; however, contrasting views remain regarding the timing of reconstruction. The mainstay article of Godina reported that reconstruction within the first three days after injury was more advantageous than surgery at later times, but different views about the best day for reconstruction have also been described in the literature. With developments in the field of microsurgery, plastic surgeons have become more experienced, shortened the times needed for surgery, and achieved flap success. We have also become more experienced with surgical times, and reconstruction on the day of injury has been performed as an emergency reconstruction (ER) procedure since 2018. However, despite the disadvantages of a delayed wait period, patients still experience delayed reconstruction (DR) due to their pre-operative conditions and dispatches from peripheral centers over delayed time periods. This study aimed to present our experiences with lower extremity reconstruction in emergency situations and after delayed periods with descriptions of technical tips for each situation. Methods: Between 2018 and 2021, patients who underwent lower extremity reconstructions were examined as retrospective case-control study. Twenty-four patients (17 male and seven female) underwent lower extremity reconstructions with microsurgical free flap coverage. Patients’ ages ranged from 6 to 75 years old. Ten patients underwent ERs (on the day of injury), and 14 patients underwent DRs. Twenty anterolateral thigh, two medial sural artery perforator, one latissimus dorsi, and one radial forearm flaps were chosen for reconstructions. Flaps were chosen for one-third of the distal lower extremity reconstructions (n=11) and Gustilo type 3B injuries (n=11), Gustilo type 3C injuries (n=1), and one-third for middle lower extremity soft tissue reconstructions (n=1). Infections, length of hospital stays, time spent during the reconstructive surgery, vascular complications, and additional debridement necessity counts were recorded and compared with previous statistical analyses. Results: One venous thrombosis in the emergency group and three venous and one arterial thrombosis in the delayed group were reported. The patients were taken to the operating room immediately after which re-anastomoses were performed successfully, and all flaps survived. The hospital stay was between 4 and 60 days in the emergency group and 20 and 99 days in delayed group. Infections (P=0.03), vascular complications (P=0.04), and hospital stays (P=0.01) were statistically significantly lower in the emergency group than in the delayed group. Conclusion: ER has many advantages, such as preventing time consuming surgeries and providing short hospital stays and low complication rates, over DR. However, DR is inevitable for some reasons, and despite its more complicated nature, meticulous flap follow-up and salvage procedures may provide the same flap success as found with ERs.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction.

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia.

Background:Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.Methods:We retrospectively reviewed patients who were treated for septic shock and developed vasopressor-induced limb ischemia at our tertiary referral academic medical center. We reviewed presentation, treatment, surgical outcomes, and long-term functional outcomes.Results:We present three previously healthy patients who developed gangrene of multiple limbs following the use of vasopressors to treat septic shock. Each patient underwent amputations or limb salvage procedures.Conclusions:Limb ischemia is a devastating complication that can occur after prolonged vasopressor use. The decision to proceed with limb salvage versus amputation of ischemic extremities should be tailored to the individual patient. The main objective should be for the patient to obtain optimal function and quality of life, regardless of the type of surgery.

Current concepts in microsurgical soft tissue reconstruction of lower extremity trauma in a single-vessel extremity

Advancements in microsurgical techniques have allowed for the salvage of extremities that would otherwise be amputated. Despite these improvements, mangling injuries of the lower extremity with concomitant open fracture continue to present a challenge for reconstructive surgeons. These injuries are further complicated by circumstances in which a single vessel is perfusing the foot after trauma (Gustilo 3C injuries). Although the foot may remain perfused in this instance, free flap coverage of open fractures with concomitant vascular injury requires careful planning to maintain a viable foot. The surgeon must adapt surgical plans based on both preoperative and intraoperative findings. In this review, we discuss current concepts and reconstructive techniques for performing free flap reconstruction in single-vessel lower extremities.

Progressive trends in timing and imaging of lower extremity reconstruction

The salvage of mangled lower-extremities after severe injury remains a daunting operative dilemma, but one that continues to evolve with advances in microsurgical and orthopedic techniques. Specifically, trends in clinical practice including the decision to salvage and timing of soft-tissue coverage are changing in concordance with improvements in wound care, flap selection for soft-tissue provision, and preoperative imaging. Due to these improvements, more complex wounds are increasingly eligible for reconstruction. It remains unclear, however, whether success in limb salvage confers improved functional patient outcomes. We present a review of the literature tracing recent advances in the salvage of mangled extremities following traumatic injury, with a focus on practice trends regarding timing of reconstruction, operative approaches, and preoperative imaging.

Abstract: Soft Tissue Reconstruction and Salvage of Infected Fixation Hardware in Lower Extremity Trauma

INTRODUCTION: Management of tibial fractures can be complicated by infection of internal fixation hardware, resulting in increased morbidity and amputation rate. When removal of infected internal hardware with external fixation is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and soft tissue coverage. The purpose of this study is to investigate salvage of lower extremities with retention of infected fixation hardware. METHODS: Tibial fractures requiring soft tissue reconstruction at a level I trauma center were reviewed from 2007–2015. Demographics, outcomes, and bacterial speciation were analyzed. The primary outcome was clinical suppression of infection, while secondary outcomes included limb salvage, hardware removal, amputation, and osseous union. RESULTS: Twenty-five patients underwent soft tissue reconstruction for salvage of infected internal fixation hardware. Average age was 41, 76% male, BMI 30.1 kg/m2, 40% of patients smoked, 96% of injuries were blunt. Tibial fractures were closed in 32%, Gustilo-Anderson grade I in 4%, II in 32%, IIIb in 20%, and IIIc in 4%. Staphylococcus was most commonly cultured with 44% methicillin-resistance. Soft tissue reconstruction was performed by local flap in 60% (73% gastrocnemius, 27% soleus), free flap in 40% (30% latissimus, 40% gracilis, 30% ALT). At 16.1 months, 76% of hardware salvage patients demonstrated clinical suppression of the infection, 57.9% rate of bony union, and 96% rate of limb salvage. One patient was amputated for recurrent infection. CONCLUSION: Following complex, infected tibial fractures, we demonstrate a 76% clinical rate of suppression of infected hardware, and 96% success in limb salvage.

Evaluation of 389 patients following free-flap lower extremity reconstruction with respect to secondary refinement procedures.

Primary functional and aesthetic results after free-flap salvage of lower extremities are occasionally suboptimal. The objective of this study was to identify predictors for secondary refinement procedures such as liposuction, dermolipectomy, or direct excision. In addition, patient-reported long-term satisfaction with the final reconstructive result was analyzed. All patients undergoing free-flap lower extremity salvage between January 2011 and July 2015 were included in a comparative study. The patients of cohort 1 had no secondary refinement procedures, while those of cohort 2 had one or more procedures. The patient data, intraoperative characteristics, and postoperative course were reviewed. To assess the level of satisfaction, the patients were surveyed. Of the 389 patients included, 54 (13.9%) were identified with 1-3 secondary refinement procedures with an uneventful postoperative course. The most common procedure was surgical debulking (56.8%). The comparison of both cohorts revealed a statistical significance for patient's age (P < .01), gender (P = .02), ASA-score (P < .01), and localization (P < .01). Predictors for secondary refinement procedures were young age (<50 years), female gender, absence of comorbidities, and defects located at the feet or ankle. Overall patient satisfaction was negatively correlated with the number of secondary procedures performed. Patient-reported satisfaction with the overall (P < .01) and cosmetic (P = .02) result increased significantly with age. Secondary refinement procedures after successful free-flap lower extremity reconstruction are safe and not uncommon. Detailed information about the likelihood of secondary operations and the various techniques available should be part of the patient education to increase patient satisfaction and form realistic expectations.

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate. MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation. ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p>.05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p>.05). The need for flap coverage was significantly associated with failed salvage of the extremity (p=.02). ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries. Type of study/level of evidenceTherapeutic III.

Treatment of Arterial Lesions in Drug Addicts

Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4±7.2years) presenting with 33 arterial lesions were treated. They presented with a humeral (n=15), femoral (n=13), or axillar (n=3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n=16), a septic syndrome (n=7), a pulsatile mass (n=6), and an acute ischemia (n=4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n=5) and medical care (n=2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. The early rate of reinterventions was 38.7% at 30days (12 patients), because of a suture line hemorrhage related to sepsis (n=6), a bypass thrombosis (n=5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n=9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6months (range: 1-73.5months), and 15 patients were lost to follow-up at 6months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.

Minimally Invasive Reconstructive Surgery for Complex Oncologic Foot Defects in Children

Sir: Recently Iorio et al.1 and previously Lee et al.2 evaluated the clinical results of the lower extremity reconstruction by using Integra, a bioengineered dermal matrix, in diabetic patients and burn injury, respectively. Iorio reviewed the use in 121 wounds and concluded that Integra is a viable option for reconstruction in diabetic patient at low risk for amputation.1 Analyzing nine complex burn injuries, Lee et al. observed Integra to be a stable wound coverage that should be considered as part of the lower extremity wound coverage algorithm.2 These authors' experience in the therapeutic challenge for the preservation of functional limb length showed that Integra provides durable coverage of vital lower extremity structures. We believe this is also a key reconstructive option in pediatric oncology patients, in which this matrix allows salvage of extremities that might be amputated or require prolonged staged procedures. We would like to report our experience with a plantar rhabdomyosarcoma in a child in which the use of Integra has allowed us to improve young patient care, with a minimally invasive reconstruction after extensive demolition in the same operative session.3 A left plantar massive neoplasm (10 × 3.7 cm) involving the flexor digitorum brevis was determined by biopsy to be alveolar rhabdomyosarcoma. Surgical resection of the tumor with total exeresis of the flexor digitorum brevis, plantar aponeurosis, and skin by en bloc radical soft-tissue excision was performed, with exposition of the flexor hallucis longus tendon, the flexor digitorum longus tendons, and the quadratus plantar muscle (Fig. 1). The wide and deep defect was reconstructed by using a single layer of Integra measuring 12.5 × 10 cm that we folded to obtain a width of 5 cm and greater thickness. By using Integra, we protect the exposed muscle-tendon structures and provide immediate wound closure, and the heel was reconstructed by suture plans. Sixteen days postoperatively, Integra was biodegraded and in its place was neodermis with full restoration of the thickness and complete preservation of the exposed structures (Fig. 2). Skin grafting restored epidermal coverage after definitive histologic assessment determined it to be tumor-free. The morphologic functional recovery of the salvaged limb was complete, with restoration of the internal longitudinal arch and normal plantar and finger flexion. At 36-month follow-up, the patient had no evidence of disease; he had regained satisfactory function and reported good quality of life, no functional limitations, and normal walking and gait. (See Video, Supplemental Digital Content 1, which demonstrates that walking is unhindered and gait is normal, https://links.lww.com/PRS/A367.)Fig. 1.: En bloc radical soft-tissue excision of 12.5 × 5 × 3 cm and exposition of the flexor hallucis longus tendon, the flexor digitorum longus tendons, and the quadratus plantar muscle (structures responsible for plantar and finger flexion).Fig. 2.: Neodermis induced by Integra.Video.: Supplemental Digital Content 1 demonstrates that walking is unhindered and gait is normal, https://links.lww.com/PRS/A367.Rhabdomyosarcoma is a highly malignant tumor and the most common soft-tissue sarcoma in children. Localization in the foot is rare. The unique anatomy of the foot presents challenges in reconstructing a viable and functional limb.4 Reconstructive surgery in children with cancer is complex and often requires multiple procedures. Free flap surgery is the most common reconstruction5 and usually results in excellent outcomes. Drawbacks are longer operative time, invasiveness and complexity of the procedure, large skin incisions, donor-site morbidity, possible flap loss or necrosis of the distal portion with delayed healing, cosmetic problems, and patient intolerance. An exclusion criterion can be situations of specific risk, such as very aggressive histologic subtypes (i.e., alveolar), where the final reconstruction should be deferred pending definitive histologic assessment. Reconstruction using Integra has allowed us to override the above-mentioned drawbacks with complete recovery. Thus, Integra following resection of a malignant plantar tumor has proven to be a successful technique, offering an important alternative to the traditional reconstructive choices. The technique is easy and minimally invasive, with operative time reduced. It avoids major complications and wide donor-site scarring. It is ideal for immediate wound closure pending final histologic assessment, simplifying wound care and improving patient tolerance, with good healing and rapid recovery. DISCLOSURE The authors have no financial interests to declare in relation to the content of this communication. No outside funding was received. Maria Giuseppina Onesti, M.D. Maria Ida Rizzo, M.D. Anna Maria Spagnoli, M.D. Nicolò Scuderi, M.D. Department of Plastic Surgery La Sapienza University of Rome Rome, Italy

Ectopic scalp replantation: A case report

Temporary ectopic implantation with secondary replantation at the anatomic site is useful in salvage of extremities or organs [Godina M, Bajec J, Baraga A. Salvage of the mutilated upper extremity with temporary ectopic implantation of the undamaged part. Plast Reconstr Surg 1986;78: 295-99; Chernofsky MA, Sauer PF. Temporary ectopic implantation. J Hand Surg [Am] 1990;15:910-14; Matloub HS, Yousif NJ, Sanger JR. Temporary ectopic implantation of an amputated penis. Plast Reconstr Surg 1994;93:408-12; Hallock GG. Transient single-digit ectopic implantation. J Reconstr Microsurg 1992;8:309-11; Graf P, Groner R, Horrl W. Temporary ectopic implantation for salvage of amputated digits. Br J Plast Surg 1996;47:174-77; Yousif NJ, Dzwierzynski WW, Anderson RC, et al. Complications and salvage of an ectopically replanted thumb. Plast Reconstr Surg 1996;97:637-40; Wang J-N, Tong Z-H, Zhang T-H, et al. Salvage of amputated upper extremities with temporary ectopic implantation followed by replantation at a second stage. J Reconstr Microsurg 2006;22:15-20]. Temporary ectopic implantation is usually considered due to poor conditions for replantation at the anatomic site. We report a case of near-total scalp avulsion treated by temporary implantation to the lower abdomen with secondary replantation.

Salvage Reconstruction of Lower Extremity Defects With Muscle Flaps

Summary: The management of lower extremity wounds has changed as reconstructive options have broadened. Free tissue transfer has enabled salvage of limbs that would have previously been amputated. At the same time, development of new local flaps has allowed successful reconstruction of wounds without the need for microsurgery. Additionally, vacuum-assisted closure therapy has dramatically impacted wound care and facilitated complex wound closure without the need for flaps (DeFranzo et al. Plast Reconstr Surg 2001;108:1184–1191). As surgical techniques have improved, the need for surgical salvage of lower extremities has concomitantly increased. The lives of multi-trauma patients, whether after a motor vehicle accident or wartime injury, are preserved at higher rates, producing more medically stable individuals with salvageable extremities. As cancer treatment improves, quality of life becomes a more important consideration, and limb-preserving surgery is more frequently expected. This article discusses methods of reconstructing complex lower extremity wounds. Surgical techniques, and anatomically based descriptions of commonly used flaps, are outlined. Perioperative management of these reconstructed extremities is also detailed.

Microsurgery for lower extremity injuries

An entire generation of orthopaedic and plastic surgeons has been indelibly and perhaps overwhelmingly influenced by the introduction of microvascular technology to the fields of limb salvage and musculoskeletal reconstruction. Free-tissue transfer using microsurgical techniques has become a valuable method for the salvage of lower extremities after trauma. The goals of free flaps are both soft-tissue coverage and improvement of the functional outcome. The flap selection criteria for lower extremity reconstruction are based on the wound surface area, the type of tissue deficiency, length of the pedicle, volume of deficient tissue components and donor site morbidity. Composite flaps represent the state-of-the-art for reconstructive microsurgery, providing more than one function. Although many different treatment protocols have been proposed, they all highlight the importance of early tissue coverage with bone management performed in a later stage.

Integra in Lower Extremity Reconstruction after Burn Injury

Standard care for lower extremity injuries with exposed bone or tendon is vascularized tissue transfer. In patients with deep and extensive burn injuries, these options are often not available or for various reasons are technically difficult. The advent of Integra, a permanent dermal replacement matrix, provides an important alternative to the traditional reconstructive choices. The authors report seven patients, with a total of nine lower extremity injuries, from the Los Angeles County and University of Southern California Hospital Burn Unit treated from September of 2001 to January of 2003 who presented with complex burn injuries involving their lower extremities with tendon, open joints, and/or bone exposure. All seven patients were treated initially with tangential excision of the burn eschar and placement of Integra. After engraftment, epidermal coverage was restored with a thin split-thickness skin graft. This treatment provided stable wound coverage, and none of the patients have required further surgical procedures to maintain wound closure. The use of a bioengineered, cell-free dermal matrix expands reconstructive options and allows salvage of extremities that might otherwise have been amputated or required prolonged, staged procedures. The authors' experience shows that Integra provides a sound alternative option for providing durable coverage of vital lower extremity structures. It should be considered as part of the lower extremity wound coverage algorithm.

A Combined Use of a Free Vascularised Flap and an External Fixator for Reconstruction of Lower Extremity Defects in Children

To describe a combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children, and correction of equinus contracture developed after removal of the external fixator using a circular dynamic frame. Seven children (4 males) aged 4 to 12 (mean, 8) years were treated with 9 free vascularised flaps for 8 limbs (bilaterally in one patient and for a failed flap in another). Patient pathologies included: 3 soft tissue degloving injuries, one soft tissue and bone avulsion, one severe burn contracture, one resurfacing of soft tissue and bone necrosis, and one osteosarcoma resection defect. Free flap reconstruction was delayed in 6 patients (range, 3 weeks to 4 years). Static external fixators were used to stabilise the free vascularised flaps at the time of reconstruction, with the ankle in a neutral position. The mean follow-up was 5 (1-10) years. All flaps but one survived; the failed one was immediately reconstructed with a contralateral, latissimus dorsi flap. One anastomosis following a Kirschner-wire injury was successfully revised. Six patients had pin tract infections and were treated with oral antibiotics. Two patients developed equinus contracture 6 and 3 years later, after removal of the external fixator, and were corrected by distraction, using a dynamic Ilizarov frame. The combined use of a free flap and an external fixator for salvage of lower extremities is useful in children. Late development of equinus contracture can be safely corrected by distraction, without compromising flap viability.

A completely shattered tibia

Despite advances in reconstructive surgery, salvage of mangled extremities still requires long periods of treatment with many operations that can be taxing both to the surgeon and the patient. Attempts at reconstruction of severely shattered limbs necessitate counselling with regard to the protracted course of treatment and associated morbidity as well as problems which may require abandoning of the procedure and secondary amputation. We report the successful salvage of a severely comminuted and open fracture of the tibia in a 32-year-old man.

Alternative Approaches to the Deep Femoral, Popliteal, and Infrapopliteal Arteries in the Leg and Foot: Part II

Use of the nonstandard, alternative approaches to infrainguinal arteries described in this article has made possible the salvage of many ischemie lower extremities that would otherwise be extremely difficult or impossible to revascularize. Most of these were in the increasing proportion of patients whose limb-threatening ischemia occurred after a primary arterial reconstruction had failed. In this setting the unusual alternative approaches facilitated secondary operations that could be performed without the need to redissect arteries through a scarred or infected wound. These approaches have also permitted shorter bypasses and thereby allowed us to use autogenous vein in patients who might otherwise have required a prosthetic graft. This is particularly important for bypass procedures that extend to infrapopliteal arteries, since vein graft patency is so much better in this location. Therefore these alternative approaches have assumed increasing importance and utility in our practice. We believe that they will be equally helpful to others as more vascular surgeons accept the premise that most limb-threatening lower extremity ischemia can and should be treated by arterial reconstruction rather than by amputation.

Very distal bypass for salvage of the severely ischemic extremity

Forty-six bypass grafts to tibial arteries distal to the ankle were performed in 35 patients for salvage of extremities threatened by gangrene or nonhealing ulcers (grade III, category 5) or ischemic rest pain (grade II, category 4). Most patients (80%) were diabetic, with severely calcified arteries, whom previously we would have considered as candidates for primary amputation. All reconstructions were performed with autologous saphenous vein. Inflow was from the common femoral artery in 5 (11%), the popliteal artery in 25 (54%), or the mid-tibial arteries in 16 (35%). Life-table analysis was used to calculate primary patency and limb salvage. Results were analyzed according to origin of inflow, outflow, or configuration of the conduit (in situ saphenous vein, n = 29 [63%], reversed saphenous vein, n = 11 [24%], or nonreversed saphenous vein, n = 6 [13%]). Overall cumulative primary graft patency at 2 years for all grafts was 72%, and the cumulative limb salvage rate was 89% for the same interval. No significant differences were seen in comparing grafts originating from the femoral or popliteal level with those arising from the tibial arteries. No significant differences were noted in graft patency or limb salvage among grafts with a posterior tibial, dorsalis pedis, or plantar artery outflow. No significant difference was noted between in situ saphenous vein grafts and reversed saphenous vein grafts. A significant decreased primary patency was noted for grafts performed with nonreversed, translocated saphenous vein. We conclude that bypass grafts to the ankle or foot vessels are beneficial and should be considered for limb salvage in extremities with gangrene, ischemic ulceration, or ischemic rest pain. In our experience, in situ saphenous vein grafts or reversed saphenous vein grafts performed similarly, whereas nonreversed saphenous vein grafts have a poorer prognosis. Vessel wall calcification requires a modification in technique for performance of these grafts but did not affect long-term performance or limb salvage, and thus should not be considered a contraindication to vascular reconstruction. The operative microscope was used in 61% (28 of 46) of these cases and found useful in creating these delicate anastomoses. Additional follow-up is needed to document the long-term results of these very distal reconstructions.

Sequential bypass grafting for salvage of lower extremities.

Since 1978, 12 patients at our institution have had distal sequential bypass grafting for limb salvage with either polytetrafluoroethylene (PTFE) or reversed saphenous vein and anastomoses to two different distal vessels. Seven patients had had previous vascular operations. One patient died of a stoke in the early postoperative period; a second patient, who was lost to follow-up several months after operation, was presumed to have died. Follow-up is otherwise complete (range seven to 48 months), without early or late limb loss. Results are encouraging and suggest that the sequential anastomotic technique may offer improved results in appropriate limb salvage cases with poor distal runoff.