- Email: [email protected]
Dorsalis pedis artery in bypass grafting
Dorsalis Pedis Artery in Bypass Grafting Wllllam Shleber, MD, St. Louis, Missouri Charles Parks, MD, St. Louis, Missouri
For many years, arterial reconstructive procedures designed to treat arterial occlusive disease involving the lower extremities were limited to the femoral and popliteal vessels. Arterial bypass procedures involving anastomoses below the knee were thought to be impossible because of the small size of the vessels involved and the limited runoff. However, as technics of vascular surgery have improved and as surgeons have become more familiar with the handling of smaller vessels, successful treatment of more distal arterial occlusions has been possible. Morris et al [I ] in 1959 described the first anastomosis of arterial grafts to the distal popliteal vessel below the knee. Two years later, McCaughan [2] described the first group of patients who had bypass grafts to vessels below the popliteal trifurcation. It soon became apparent that vessels distal to the popliteal artery would support inserted autogenous saphenous vein grafts [3-101. Thereafter, the frequency of arterial bypass grafting to the anterior tibial, posterior tibial, and peroneal arteries in the calf region increased rapidly. More recently, refinements in surgical technics for suturing vessels 2 mm in diameter have resulted in favorable patency rates for arterial anastomoses at the ankle and below [11-141. This report is an analysis of sixteen patients in whom the dorsalis pedis artery was utilized for the distal anastomosis in bypass grafting for arterial occlusive disease. From the Washington University School of Medicine and The Waldheim Department of Surgery, The Jewish Hospital of St. Louis, St. Louis, Missouri. Reprint requests should be addressed to Dr William Shieber, Department of Surgery, Jewish HospiRalof St. Louis, 216 S. Kingshighway, St. Louis, Missouri 63 1 IO. Presented at the Twenty-Sixth Annual Meeting of the Southwestern Surgical Congress. Monterey, California, April 29 to May 2, 1974.
752
Material and Methods Since 1967 at The Jewish Hospital of St. Louis, sixteen patients have had autogenous saphenous vein bypass grafts inserted into the dorsalis pedis artery. Seven patients were male and nine were female with ages ranging from fifty-eight to eighty-eight years. All patients were diabetic. Surgery was performed in all patients for problems of limb salvage. Eight patients had minor degrees of gangrene, six had nonhealing ulcers, and two had rest pain. No patient whose only symptom was claudication was operated on. Significant and widespread vascular disease was present in all patients. Eleven of the sixteen patients had experienced previous myocardial infarction, three had previous cerebrovascuiar accidents, and five had previous operative procedures on the opposite leg for arterial occlusive disease. Five patients required amputation of some part of the opposite lower limb preoperatively, and one required a femoropopliteal bypass graft in the opposite limb postoperatively. Ten of the sixteen procedures were popliteal to dorsalis pedis bypass grafts; six were femoral to dorsalis pedis grafts. All grafts were reversed autogenous vein grafts. Surgery was performed utilizing either general, spinal, or continuous epidural anesthesia. The entire abdomen and appropriate lower extremity were prepared with Betadinee and draped in the standard sterile fashion. A curvilinear incision was made on the dorsum of the foot beginning in the interosseous space between the first and second metatarsal bones overlying the dorsalis pedis artery. (Figure 1.) This incision was curved anterior to the medial malleolus and continued proximally up the medial aspect of the calf over the course of the great saphenous vein. The great saphenous vein was then removed from this single, continuous, long incision from its distal margin anterior to the medial malleolus for a length that was suitable for the required grafting distance. As many tributaries as possible were ligated at
The American Journal of Surgery
the time of removal of the vein. Nonabsorbable sutures (usually Teflon”-coated Dacron@) were used throughout the procedure. An olive-tipped, short metal cannula was inserted and tied into the distal end of the removed vein. Saline was injected to flush out the blood, to dilate the vein, and to indicate any points of leakage. Any leaking tributaries were ligated with 5-O ligatures or sutured with 6-O sutures. The adventitia was stripped as necessary so that any constricting bands were removed and examination indicated that the vessel was at least 4 to 5 mm in .diameter at its narrowest point. To avoid twisting the graft during the tunneling procedure, we drew a longitudinal line with a methylene blue marking pen down the entire length of the graft while it was lying flat on the operating table. This line was invaluable in maintaining orientation of the graft. After the graft was marked, it was wrapped in a sterile sponge and set aside. Systemic heparinization was then performed with 6,000 to 7,000 units of intravenous heparin. The dorsalis pedis artery was occluded using two small Schwartz neurosurgical aneurysm clips. A longitudinal incision twice the diameter of the vein was made in the dorsalis pedis artery. A standard “fish-mouth” anastomosis as originally described by Kunlin [15] utilizing 6-O Tefloncoated Dacron sutures was constructed. (Figure 2.) We have found that the use of ophthalmologic needle holders and tissue forceps and a 2 to 3 power loupe, having a convenient focal length and sufficient depth of field, has been a great aid in the performance of the small anastomosis. The final sutures of the distal anastomoses were not tied but allowed to lie loosely, thus maintaining an open site in the anastomosis for later flushing of the graft. The graft was then brought medially, anterior to the medial malleolus in the subcutaneous tissue, in the plane from which the saphenous vein was removed. At approximately the mid calf level, the vein was brought through the crural fascia and passed deep to the medial head of the gastrocnemius muscle and then into the popliteal space. If there was minimal evidence of atherosclerosis in the superficial femoral artery (as has been encountered in many diabetic patients), the graft was anastomosed to the popliteal artery, again using a standard end to side “fish-mouth” anastomosis. If there was significant stenosis or obstruction of the superficial femoral artery, the graft was tunneled up the course of the superficial femoral and popliteal arteries to the common femoral artery. The proximal anastomosis was then made to the common femoral artery. After both anastomoses had been constructed, the graft was flushed through the partially opened distal anastomosis. When there was satisfactory flow through the graft, the distal anastomosis was completed by tightening the previously placed but untied sutures. The wounds were then closed in layers utilizing interrupted sutures. Sympathectomy has not been performed in any of these patients. Anticoagulation or dextran has not been used postoperatively. Ambulation has been allowed on
vahmw 128, Docomber 1974
Flgure 1. lncf&n for popttteal dotsa& pedh saphenow vein bypaw graly along couree of the saphenous vein.
the first postoperative day. Postoperative edema has been controlled by elevation of the leg, administration of diuretics, limitation of sodium, and occasionally, if persistent, use of elastic stockings. We have not employed routine postoperative prophylactic antibiotic therapy. However, appropriate antibiotics have been used when open ulcers or infections were present. The choice of antibiotics is dictated by the sensitivity results of the culture of the infected material. Results There were two early patency failures. failure was secondary to an inadequate
One early
vein. This patient later required a below the knee amputation. The other early failure occurred in an elderly man who experienced a massive cerebrovascular accident on the sixth postoperative day, resulting in spastic crossing of the legs. He had mechanical occlusion of the graft by compression of the graft against the tibia at the ankle. He died two days later of another cerebrovascular accident. One other patient died of a myocardial infarction on the second postoperative day. Therefore, thirteen of the sixteen patients were discharged from the hospital with functioning grafts. There has been only one late graft thrombosis in a patient three
Flgure 2. Saphenous vein to dorsal/s pedia artery anastomasts wfth vascular occluding clamps.
753
Shieber and Parks
follow-up period has been three to fifty-nine months with an average of twenty months. Of the seven patients who died with patent grafts, the follow-up period was three to fifty-four months with an average of 18.4 months. Of the sixteen patients, only two required amputation postoperatively, and these were below the knee amputations. Comments
Flgure 3. Postoperative arteriogram showing patent grafts from popMeal to dorsalis pedis artery. Figure 4. Postoperatlve arteriogram showing common femoral to dorsal& pedts graft. Superfkial femoral artery provided insufficient Inflow for pop/Mea/ to dorsalis pedis graft.
months postoperatively. Shortly thereafter, she required a below the knee amputation. She subsequently died of a myocardial infarction. Seven of the remaining twelve patients subsequently died of manifestations of the basic process, atherosclerosis, or either a myocardial infarction or cerebrovascular accident. All of these patients had patent grafts and intact limbs at the time of death. Therefore, at the present time there are five surviving patients, all of whom have patent grafts. The longest period of patency has been fifty-nine months; this occurred in a man who is still alive and has an intact patent graft and a surviving limb. One patient died fifty-four months postoperatively with a patent graft and an intact limb. Of the five patients surviving with patent grafts, the
754
With refinements in the technic of small vessel anastomosis and a better understanding of the principles of grafting in relation to inflow and outflow requirements, successful grafting to the infrapopliteal arteries has become frequent. Thus, limb salvage can now be achieved in many patients previously considered inoperable. (Figures 3 and 4.) Because the anterior tibial, posterior tibial, and peroneal arteries lie deep in the calf, anastomosis to these vessels presents significant technical problems since they lie in an inaccessible region. The dorsalis pedis artery lying superficially within the dorsum of the foot has served as an attractive alternative in revascularization of the lower extremity. This artery has frequently been found to be patent in patients with popliteal and infrapopliteal occlusions. Its superficial position makes it readily accessible for anastomosis with minimal dissection for exposure. Its size is satisfactory for anastomosis (usually measuring approximately 2 mm in diameter). The results in these patients indicate that the dorsalis pedis artery will definitely support a vein graft and supply sufficient blood flow for revascularization of an ischemic limb. Thus, no severely ischemic limb should be considered inoperable for revascularization until adequate arteriography has been performed, outlining the vessels not only of the knee and calf region but also of the foot and ankle. Conclusions
The dorsalis pedis artery provides a site for distal anastomosis in patients with arterial occlusive disease of the popliteal and infrapopliteal vessels who have severe ischemia. Since April 1967, the dorsalis pedis artery has been used as the site of distal anastomosis in sixteen patients. Both the short- and long-term patency rates for dorsalis pedis grafting have been high and revascularization of the limb, utilizing this single vessel, is readily accomplished. Its superficial position in the foot, allowing ready access and easy exposure, makes it an attractive alternative to other infrapopliteal vessels as a site of distal anastomosis.
The American Journal of Surgery
Bypass Grafting
References 1. Morris GC Jr, DeBakey ME, Cooley DA, Crawford ES: Atterial bypass below the knee. Surg Gynecol Obstet 106: 321, 1959. 2. McCaughan JJ Jr: Successful arterial grafts to the anterior tibial, posterior tibia1 (below the peroneal) and peroneal arteries. AngioIogy 12: 91, 1961. 3. Bernhard VM, Ashmore CS, Evans WE, Rodgers RE: Bypass grafting to distal arteries for limb salvage. Surg Gynecol Obstet 135: 219, 1972. 4. Reichle FA, Tyson RR: Bypasses to tibia1 or popliteal arteries in severely ischemic lower extremities: comparison of long-term results in 233 patients. Ann Surg 176: 315, 1972. 4. Kaminski DL, Barner HB, Dorighi JA, Kaiser GC, Willman VL: Femoral-tibia1 bypass grafting. Arch Surg 104: 527, 1972. 6. Garrett HE, DeBakey ME: Distal posterior tibia1 artery bypass with autogenous vein graft: a report of three cases. Surgery 60: 263, 1966. 7. Minken SL, May AG: Use of peroneal artery for revascular-
voklme 12s. December 1974
ization of the lower extremity. Arch Surg 99: 594, 1969. 6. Tyson RR, Reichle FA: Femorotibiil bypass for salvage of the ischemic lower extremity. Surg Gynecol Obstet 134: 771,1972. 9. Noon GP, Diethrich EB, Richardson WP, DeBakey ME: Distal tibia1 arterial bypass: analysis of 91 cases. Arch Surg 99: 770, 1969. 10. Garrett HE, Ketch PI, Green MT Jr, Diethrich EB. DeBakey
11. 12. 13.
14. 15.
ME: Distal tibia1 artery bypass with autogenous vein grafts: an analysis of 56 cases. Surgery 63: 90, 1966. Shieber W: Popliieal to dorsalis pedis by-pass: case reports. Mo Med 66: 191, 1969. Foster RP, Yonke BP: Extremity salvage: vein bypass to the ankle level and beyond. Vast Surg 5: 12, 197 1. Baird RJ, Tutassaura H, Miyagishima RT: Saphenous vein bypass grafts to the arteries of the ankle and foot. Ann Surg 172: 1059. 1970. Auer Al, Hershey FB: Bypass vein grafts to distal tibia1 or dorsalis pedis arteries. Mo A&d 70: 93, 1973. Kunlin J: Long vein transplantation and treatment of ischemia caused by arteritis. Rev chir 70: 206, 195 1.
755
For many years, arterial reconstructive procedures designed to treat arterial occlusive disease involving the lower extremities were limited to the femoral and popliteal vessels. Arterial bypass procedures involving anastomoses below the knee were thought to be impossible because of the small size of the vessels involved and the limited runoff. However, as technics of vascular surgery have improved and as surgeons have become more familiar with the handling of smaller vessels, successful treatment of more distal arterial occlusions has been possible. Morris et al [I ] in 1959 described the first anastomosis of arterial grafts to the distal popliteal vessel below the knee. Two years later, McCaughan [2] described the first group of patients who had bypass grafts to vessels below the popliteal trifurcation. It soon became apparent that vessels distal to the popliteal artery would support inserted autogenous saphenous vein grafts [3-101. Thereafter, the frequency of arterial bypass grafting to the anterior tibial, posterior tibial, and peroneal arteries in the calf region increased rapidly. More recently, refinements in surgical technics for suturing vessels 2 mm in diameter have resulted in favorable patency rates for arterial anastomoses at the ankle and below [11-141. This report is an analysis of sixteen patients in whom the dorsalis pedis artery was utilized for the distal anastomosis in bypass grafting for arterial occlusive disease. From the Washington University School of Medicine and The Waldheim Department of Surgery, The Jewish Hospital of St. Louis, St. Louis, Missouri. Reprint requests should be addressed to Dr William Shieber, Department of Surgery, Jewish HospiRalof St. Louis, 216 S. Kingshighway, St. Louis, Missouri 63 1 IO. Presented at the Twenty-Sixth Annual Meeting of the Southwestern Surgical Congress. Monterey, California, April 29 to May 2, 1974.
752
Material and Methods Since 1967 at The Jewish Hospital of St. Louis, sixteen patients have had autogenous saphenous vein bypass grafts inserted into the dorsalis pedis artery. Seven patients were male and nine were female with ages ranging from fifty-eight to eighty-eight years. All patients were diabetic. Surgery was performed in all patients for problems of limb salvage. Eight patients had minor degrees of gangrene, six had nonhealing ulcers, and two had rest pain. No patient whose only symptom was claudication was operated on. Significant and widespread vascular disease was present in all patients. Eleven of the sixteen patients had experienced previous myocardial infarction, three had previous cerebrovascuiar accidents, and five had previous operative procedures on the opposite leg for arterial occlusive disease. Five patients required amputation of some part of the opposite lower limb preoperatively, and one required a femoropopliteal bypass graft in the opposite limb postoperatively. Ten of the sixteen procedures were popliteal to dorsalis pedis bypass grafts; six were femoral to dorsalis pedis grafts. All grafts were reversed autogenous vein grafts. Surgery was performed utilizing either general, spinal, or continuous epidural anesthesia. The entire abdomen and appropriate lower extremity were prepared with Betadinee and draped in the standard sterile fashion. A curvilinear incision was made on the dorsum of the foot beginning in the interosseous space between the first and second metatarsal bones overlying the dorsalis pedis artery. (Figure 1.) This incision was curved anterior to the medial malleolus and continued proximally up the medial aspect of the calf over the course of the great saphenous vein. The great saphenous vein was then removed from this single, continuous, long incision from its distal margin anterior to the medial malleolus for a length that was suitable for the required grafting distance. As many tributaries as possible were ligated at
The American Journal of Surgery
the time of removal of the vein. Nonabsorbable sutures (usually Teflon”-coated Dacron@) were used throughout the procedure. An olive-tipped, short metal cannula was inserted and tied into the distal end of the removed vein. Saline was injected to flush out the blood, to dilate the vein, and to indicate any points of leakage. Any leaking tributaries were ligated with 5-O ligatures or sutured with 6-O sutures. The adventitia was stripped as necessary so that any constricting bands were removed and examination indicated that the vessel was at least 4 to 5 mm in .diameter at its narrowest point. To avoid twisting the graft during the tunneling procedure, we drew a longitudinal line with a methylene blue marking pen down the entire length of the graft while it was lying flat on the operating table. This line was invaluable in maintaining orientation of the graft. After the graft was marked, it was wrapped in a sterile sponge and set aside. Systemic heparinization was then performed with 6,000 to 7,000 units of intravenous heparin. The dorsalis pedis artery was occluded using two small Schwartz neurosurgical aneurysm clips. A longitudinal incision twice the diameter of the vein was made in the dorsalis pedis artery. A standard “fish-mouth” anastomosis as originally described by Kunlin [15] utilizing 6-O Tefloncoated Dacron sutures was constructed. (Figure 2.) We have found that the use of ophthalmologic needle holders and tissue forceps and a 2 to 3 power loupe, having a convenient focal length and sufficient depth of field, has been a great aid in the performance of the small anastomosis. The final sutures of the distal anastomoses were not tied but allowed to lie loosely, thus maintaining an open site in the anastomosis for later flushing of the graft. The graft was then brought medially, anterior to the medial malleolus in the subcutaneous tissue, in the plane from which the saphenous vein was removed. At approximately the mid calf level, the vein was brought through the crural fascia and passed deep to the medial head of the gastrocnemius muscle and then into the popliteal space. If there was minimal evidence of atherosclerosis in the superficial femoral artery (as has been encountered in many diabetic patients), the graft was anastomosed to the popliteal artery, again using a standard end to side “fish-mouth” anastomosis. If there was significant stenosis or obstruction of the superficial femoral artery, the graft was tunneled up the course of the superficial femoral and popliteal arteries to the common femoral artery. The proximal anastomosis was then made to the common femoral artery. After both anastomoses had been constructed, the graft was flushed through the partially opened distal anastomosis. When there was satisfactory flow through the graft, the distal anastomosis was completed by tightening the previously placed but untied sutures. The wounds were then closed in layers utilizing interrupted sutures. Sympathectomy has not been performed in any of these patients. Anticoagulation or dextran has not been used postoperatively. Ambulation has been allowed on
vahmw 128, Docomber 1974
Flgure 1. lncf&n for popttteal dotsa& pedh saphenow vein bypaw graly along couree of the saphenous vein.
the first postoperative day. Postoperative edema has been controlled by elevation of the leg, administration of diuretics, limitation of sodium, and occasionally, if persistent, use of elastic stockings. We have not employed routine postoperative prophylactic antibiotic therapy. However, appropriate antibiotics have been used when open ulcers or infections were present. The choice of antibiotics is dictated by the sensitivity results of the culture of the infected material. Results There were two early patency failures. failure was secondary to an inadequate
One early
vein. This patient later required a below the knee amputation. The other early failure occurred in an elderly man who experienced a massive cerebrovascular accident on the sixth postoperative day, resulting in spastic crossing of the legs. He had mechanical occlusion of the graft by compression of the graft against the tibia at the ankle. He died two days later of another cerebrovascular accident. One other patient died of a myocardial infarction on the second postoperative day. Therefore, thirteen of the sixteen patients were discharged from the hospital with functioning grafts. There has been only one late graft thrombosis in a patient three
Flgure 2. Saphenous vein to dorsal/s pedia artery anastomasts wfth vascular occluding clamps.
753
Shieber and Parks
follow-up period has been three to fifty-nine months with an average of twenty months. Of the seven patients who died with patent grafts, the follow-up period was three to fifty-four months with an average of 18.4 months. Of the sixteen patients, only two required amputation postoperatively, and these were below the knee amputations. Comments
Flgure 3. Postoperative arteriogram showing patent grafts from popMeal to dorsalis pedis artery. Figure 4. Postoperatlve arteriogram showing common femoral to dorsal& pedts graft. Superfkial femoral artery provided insufficient Inflow for pop/Mea/ to dorsalis pedis graft.
months postoperatively. Shortly thereafter, she required a below the knee amputation. She subsequently died of a myocardial infarction. Seven of the remaining twelve patients subsequently died of manifestations of the basic process, atherosclerosis, or either a myocardial infarction or cerebrovascular accident. All of these patients had patent grafts and intact limbs at the time of death. Therefore, at the present time there are five surviving patients, all of whom have patent grafts. The longest period of patency has been fifty-nine months; this occurred in a man who is still alive and has an intact patent graft and a surviving limb. One patient died fifty-four months postoperatively with a patent graft and an intact limb. Of the five patients surviving with patent grafts, the
754
With refinements in the technic of small vessel anastomosis and a better understanding of the principles of grafting in relation to inflow and outflow requirements, successful grafting to the infrapopliteal arteries has become frequent. Thus, limb salvage can now be achieved in many patients previously considered inoperable. (Figures 3 and 4.) Because the anterior tibial, posterior tibial, and peroneal arteries lie deep in the calf, anastomosis to these vessels presents significant technical problems since they lie in an inaccessible region. The dorsalis pedis artery lying superficially within the dorsum of the foot has served as an attractive alternative in revascularization of the lower extremity. This artery has frequently been found to be patent in patients with popliteal and infrapopliteal occlusions. Its superficial position makes it readily accessible for anastomosis with minimal dissection for exposure. Its size is satisfactory for anastomosis (usually measuring approximately 2 mm in diameter). The results in these patients indicate that the dorsalis pedis artery will definitely support a vein graft and supply sufficient blood flow for revascularization of an ischemic limb. Thus, no severely ischemic limb should be considered inoperable for revascularization until adequate arteriography has been performed, outlining the vessels not only of the knee and calf region but also of the foot and ankle. Conclusions
The dorsalis pedis artery provides a site for distal anastomosis in patients with arterial occlusive disease of the popliteal and infrapopliteal vessels who have severe ischemia. Since April 1967, the dorsalis pedis artery has been used as the site of distal anastomosis in sixteen patients. Both the short- and long-term patency rates for dorsalis pedis grafting have been high and revascularization of the limb, utilizing this single vessel, is readily accomplished. Its superficial position in the foot, allowing ready access and easy exposure, makes it an attractive alternative to other infrapopliteal vessels as a site of distal anastomosis.
The American Journal of Surgery
Bypass Grafting
References 1. Morris GC Jr, DeBakey ME, Cooley DA, Crawford ES: Atterial bypass below the knee. Surg Gynecol Obstet 106: 321, 1959. 2. McCaughan JJ Jr: Successful arterial grafts to the anterior tibial, posterior tibia1 (below the peroneal) and peroneal arteries. AngioIogy 12: 91, 1961. 3. Bernhard VM, Ashmore CS, Evans WE, Rodgers RE: Bypass grafting to distal arteries for limb salvage. Surg Gynecol Obstet 135: 219, 1972. 4. Reichle FA, Tyson RR: Bypasses to tibia1 or popliteal arteries in severely ischemic lower extremities: comparison of long-term results in 233 patients. Ann Surg 176: 315, 1972. 4. Kaminski DL, Barner HB, Dorighi JA, Kaiser GC, Willman VL: Femoral-tibia1 bypass grafting. Arch Surg 104: 527, 1972. 6. Garrett HE, DeBakey ME: Distal posterior tibia1 artery bypass with autogenous vein graft: a report of three cases. Surgery 60: 263, 1966. 7. Minken SL, May AG: Use of peroneal artery for revascular-
voklme 12s. December 1974
ization of the lower extremity. Arch Surg 99: 594, 1969. 6. Tyson RR, Reichle FA: Femorotibiil bypass for salvage of the ischemic lower extremity. Surg Gynecol Obstet 134: 771,1972. 9. Noon GP, Diethrich EB, Richardson WP, DeBakey ME: Distal tibia1 arterial bypass: analysis of 91 cases. Arch Surg 99: 770, 1969. 10. Garrett HE, Ketch PI, Green MT Jr, Diethrich EB. DeBakey
11. 12. 13.
14. 15.
ME: Distal tibia1 artery bypass with autogenous vein grafts: an analysis of 56 cases. Surgery 63: 90, 1966. Shieber W: Popliieal to dorsalis pedis by-pass: case reports. Mo Med 66: 191, 1969. Foster RP, Yonke BP: Extremity salvage: vein bypass to the ankle level and beyond. Vast Surg 5: 12, 197 1. Baird RJ, Tutassaura H, Miyagishima RT: Saphenous vein bypass grafts to the arteries of the ankle and foot. Ann Surg 172: 1059. 1970. Auer Al, Hershey FB: Bypass vein grafts to distal tibia1 or dorsalis pedis arteries. Mo A&d 70: 93, 1973. Kunlin J: Long vein transplantation and treatment of ischemia caused by arteritis. Rev chir 70: 206, 195 1.
755