- Email: [email protected]
Limb salvage procedures for lower extremity ischemia
Limb Salvage Procedures for Lower Extremity lschemia George J. Collins, Jr, MD, LTC, MC, Washington, DC Norman M. Rich, MD, FACS, COL, MC, Washington, DC Charles A. Andersen, MD, MAJ, MC, Washington, DC
Ischemia of the lower extremities is at times so severe that it threatens not only the survival of the extremity but also that of the patient. Many patients presenting with this degree of ischemia are poor surgical risks because of preexisting or concomitant disease processes. For this reason, it is important to know whether the risks of operation are low enough and the chances of success high enough to warrant arterial reconstruction. The alternative of amputation is not without considerable hazard, requires exhaustive rehabilitation, and leaves a permanent deficit. In an attempt to clarify these issues, we reviewed our experience at Walter Reed Army Medical Center, from 1965 to 1975, in treating patients in whom the indication for operation was threatened lower limb loss. Material and Methods Adequate records bearing on this study which were available from 1965 forward were included in this retrospective review. One of us (NMR) has been involved in the medical care of all patients in this series. The establishment of-an independent Vascular Clinic, Clinical Laboratory, and Registry at Walter Reed General Hospital made this study possible. A copy of permanent medical records remains on file in the Registry. Routine follow-up at sched-
uled intervals averaging three to six months has been the goal of the overall clinical evaluation. Only patients with rest pain requiring revascularization or amputation, with severe pregangrenous changes necessitating urgent or emergent operation, and with ischemic tissue necrosis and ulceration were included. Emergency patients in whom limb loss without operation could not be predicted with relative certainty from available data, were eliminated from the study. The most important parameters in this review were number of procedures performed each year, age and sex distribution, types and frequency of procedures performed, From the Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC. Reprint requests should be addressed to George J. Collins, Jr, MD, LTC, MC, Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20012. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6, 1976.
Volume 132, December 1976
whether the procedure was a primary operation or reoperation, number and types of associated illnesses, amputation rates, and patency rates in the early postoperative period and at last follow-up. Results
During the period from 1965 to 1975, ninety patients (82 per cent males, 18 per cent females) had limb salvage procedures. Very few procedures were performed in the early years, whereas there has been a progressive increase in the number of cases each year since 1972 (19652; 1966,O; 1967,3; 1963,5; 1969, 1; 1970,6; 1971, 5; 1972, 8; 1973, 16; 1974, 21; 1975, 23). The average age of patients undergoing these procedures was fifty-seven years (range, 23 to 90 years). The indications for operation were rest pain in eight patients (8.9 per cent), ischemic necrosis and ulceration in twenty-six (28.9 per cent), and pregangrene in fifty-six (62.2 per cent). As outlined in Table I, there was a high incidence of associated or prior significant illnesses. Cardiovascular disease was the most common associated illness, occurring in 41.0 per cent of patients. The types of cardiovascular illnesses were prior myocardial infarction (14.4 per cent), congestive heart failure (10 per cent), hypertension (7.8 per cent), angina pectoris (4.4 per cent), and arrhythmia (4.4 per cent). Diabetes mellitus occurred in 22.2 per cent and thrombophlebitis occurred in 10 per cent of patients. As shown in Table II, sixteen types of procedures were performed. The most commonly performed operations were femoropoplitea1 bypass and aortofemoral bypass. In fifty-seven patients (63.3 per cent) the operation was primary and in thirty-three (36.7 per cent) the patient had had one or more previous vascular reconstructive procedures. Complications severe enough to prolong hospitalization, exclusive of amputations, occurred in eight patients (8.9 per cent), and the thirty day mortality rate was 8.9 per cent. Nine additional patients have died during the follow-up period. Patency was most commonly judged by palpable pulses or audible Doppler flow with improved ankle pressures. Postoperative arteriograms have been
707
Collins, Rich, and Andersen
TABLE
Illnesses in Limb Salvage Procedures
I Associated or Prior Significant Patients Undergoing (90 patients)
Cardiovascular disease Diabetes mellitus Thrombophlebitis Cerebrovascular accident Peptic ulcer disease Alcoholism Obstructive pulmonary disease Cancer Rheumatoid arthritis Pyoderma Infected prosthesis
II
Types and Frequency of Limb Salvage Procedures Performed Procedure
Number
Percentage
37 20 9 6 6 4 3 3 2 1 1
41.0 22.2 10.0 6.7 6.7 4.4 3.3 3.3 2.2, 1.1 1.1
performed in some patients. The early (less than 30 days) patency rate, exclusive of patients having expired and those having had sympathectomy only, was 79.7 per cent (63 of 79 were patent). At last follow-up, the adjusted patency rate (number patent/number alive) was 73.9 per cent @l/70). The amputation rate at thirty days was 14 per cent (13 patients) and only two surviving patients have had subsequent amputation, for an overall amputation rate of 16 per cent. Accurate recordings of both preoperative and postoperative ankle pressures were available in forty-nine patients. In considering affected vs unaffected limbs, the average preoperative ankle pressure, was 40.6 mm Hg in affected limbs and 124.5 mm Hg in unaffected limbs. At last follow-up the average ankle pressure was 115.0 mm Hg in previously affected limbs and 120.5 mm Hg in previously unaffected limbs. The difference between the mean preoperative ankle pressure in affected limbs and the mean ankle pressure in affected limbs at last follow-up was statistically significant (p
The results of this study indicate that operative attempts at lower extremity salvage are warranted in most patients. Although the complication rate of 8.9 per cent and the thirty day mortality rate of 8.9 per cent might be considered high, this must be contrasted with age-related mortality rates for amputation ranging from 7.9 to 16.4 per cent as reported by Kihn, Warren, and Beebe [1] and with the 11 per cent mortality rate cited by Mannick and Hume [2]. Our morbidity and mortality rates are comparable to those of other authors [3,4]. In a series of patients having femorotibial or femoroperoneal bypasses for extremity salvage, Jolly, Hill, and Herman [3] reported an early mortality rate of 4.8 per cent, with 24
708
TABLE
Number
Femoropopliteal bypass Aortofemoral bypass Extra-anatomic bypass Femoral thromboendarterectomy Aortopopliteal bypass Sympathectomy Femorotibial bypass Popliteal embolectomy Femoroprofundaplasty Popliteal thrombectomy Popliteal endarterectomy Aortoiliac endarterectomy Fasciotomy Femoroperoneal bypass Popliteal-tibia1 bypass Popliteal-popliteal bypass
26 19 12 10 3 3 3 2 2 2 2 2 1 1 1 1
per cent late deaths. Mortality rates ranging from 8 to 24 per cent were reported for high risk patients undergoing aortofemoral bypass for extremity salvage by Wesolowski et al [4]. Reichle and Tyson [5] have achieved rather low mortality rates in patients undergoing femoropopliteal (3.1 per cent) or femorotibial(2.9 per cent) bypass for limb salvage. Noon et al [6] have reported low in-hospital mortality rates (2.2 per cent) with distal bypass procedures for limb salvage. Mortality rate relates more to the preoperative condition of the patient than to the procedure performed. This has recently been emphasized by Freund, Romanoff, and Floman [7] who reported mortality rates after balloon catheter arterial embolectomy of 41 per cent. There is no sound basis for contesting the superiority of one procedure over another. As noted in Table II, the surgeon dealing with these types of patients must have at his disposal an armamentariurn comprised of many different procedures. The procedure must be tailored to the needs of each patient. It may be as simple as a fasciotomy, as in one of our patients with blunt trauma to the popliteal space, or as complex as an aortopopliteal bypass even though this procedure is frequently unsuccessful, as reported by Benson et al [8]. In general, success will be frequent if the most proximal obstruction is corrected first. In some cases, two procedures, such as an aortofemoral bypass combined with a femoropopliteal bypass or femorotibial bypass, may be necessary. This situation arises only infrequently and, in general, we have avoided simultaneous combined procedures. Extra-anatomic bypass procedures, such as axillofemoral bypass and femorofemoral bypass, have been a significant advancement,
The American Journal of Surgery
Lower Extremity lschemia
allowing one to perform frequently successful procedures with relatively low morbidity and mortality rates [g-11]. We have observed an increasing trend in our own practice to use such procedures for limb salvage in high risk patients. With the bulk of our experience being in recent years, our results do not reflect meaningful long-term patency rates. The early patency rate of 79.7 per cent and the patency rate at last follow-up of 72.9 per cent have encouraged us to attempt revascularization in almost all patients with limb-threatening ischemia. Only those with obviously far advanced gangrenous changes, those in whom the chance of success is negligible due to poor runoff, and those with severe associated diseases and marginal chances of success are considered for primary amputation. In these latter patients, a primary amputation might be considered less life-threatening than an extensive revascularization attempt soon to be followed by the associated morbidity and mortality of an amputation should the revascularization attempt fail. Summary Limb salvage procedures were performed in ninety patients during the period from 1965 to 1975. Sixteen different procedures were performed with an associated complication rate of 8.9 per cent and a mortality rate of 8.9 per cent. The patency rates were 79.7 per cent at thirty days and 72.9 per cent at last follow-up. References 1. Kihn FiB, Warren R, Beebe GW: The geriatric amputee. Ann Surg 176: 305, 1972. 2. Mannick JA. Hume DM: Salvage of extremities by vein grafts in far-advanced peripheral vascular disease. Surgery 155: 154,1964. 3. Jolly PC, Hill LD, Herman ML: Extremity salvage by small vessel revascularization. Am Surg 40: 521, 1974. 4. Wesolowski SA, Martinez A, Domingo RT, Fries CC, Schaefer HC. Sawyer PN, Gillie E, McMahon JD: Indications for aortofemoral arterial reconstruction: a study of borderline risk patients. Surgery 60: 288, 1966. 5. Reichle FA, Tyson RR: Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities. Ann Surg 18: 449, 1975. 6. Noon GP, Diethrich EB, Richardson WP, DeBakey ME: Distal tibia1 arterial bypass, analysis of 91 cases. Arch Surg 99:
Volume 132, December 1976
770, 1969. 7. Freund U, Romanoff l-t, Floman Y: Mortality rate following lower limb arterial embolectomy: causative factors. Surgery 77: 201,1975. 8. Benson JR, Whelan TJ, Cohen A, Spencer FC: Combined aorta-iliac and femoropopliteal occlusive disease: limitations of total aortofemoropopliteal bypass. Ann Surg 163: 121, 1966. 9. Moore WS, Hall AD, Blaisdell FW: Late results of axillaryfemoral bypass grafting. AmJSurg 122: 148, 1971. 10. Ayvazian VH, Auer Al, Hershey FB: Limb salvage by extended femorofemoral bypass. Surg Gynecol Of&et 135: 737, 1972. 11. Vetto RM: The femorofemoral shunt. An Appraisal. Am J Surg 112: 162.1966.
Discussion George Noon (Houston, TX): Did you use lumbar sympathectomy? Do you have a breakdown as to the acute or chronic nature of limb ischemia? I find preoperative arteriograms very valuable. If we stay in the femoral or popliteal artery above the knee, we can expect long-term patency with our grafts. However, even if the distal tibia1 bypass remains open only three to six months, it may save the limb by allowing healing of the skin ulcerations. I like to perform arteriography at operation to determine the state of distal circulation and to provide a basis for further surgery if necessary.
Falls B. Hershey (St. Louis, MO): I rise to compare our series of long vein grafts. These operations save legs but do not prolong life. We reported our first twenty-four cases at the Western Surgical Association some years ago and now have forty-five cases. These are elderly persons with gangrene of the toes or ischemic ulcers and widespread atherosclerosis. Mortality is high-15 per cent in the first month and 30 per cent in the first year. Operation was to avoid amputation. Only three legs were lost among the survivors. Twenty-five per cent of the survivors died of other causes, the graft being open. There were three late closures requiring amputation some years after operation. If the long grafts remain open a few months, the outlook is good. George J. Collins, Jr (closing): We have rarely used sympathectomy alone and have not performed concomitant sympathectomy for limb salvage. Results for the acute ischemia were very good. Patients with ischemic necrosis and ulceration had the worst sequelae. I concur that arteriograms are valuable, especially in diabetics and if distal bypass is being considered. We agree with Doctor Hershey that mortality depends more on the generalized atherosclerotic process.
709
Ischemia of the lower extremities is at times so severe that it threatens not only the survival of the extremity but also that of the patient. Many patients presenting with this degree of ischemia are poor surgical risks because of preexisting or concomitant disease processes. For this reason, it is important to know whether the risks of operation are low enough and the chances of success high enough to warrant arterial reconstruction. The alternative of amputation is not without considerable hazard, requires exhaustive rehabilitation, and leaves a permanent deficit. In an attempt to clarify these issues, we reviewed our experience at Walter Reed Army Medical Center, from 1965 to 1975, in treating patients in whom the indication for operation was threatened lower limb loss. Material and Methods Adequate records bearing on this study which were available from 1965 forward were included in this retrospective review. One of us (NMR) has been involved in the medical care of all patients in this series. The establishment of-an independent Vascular Clinic, Clinical Laboratory, and Registry at Walter Reed General Hospital made this study possible. A copy of permanent medical records remains on file in the Registry. Routine follow-up at sched-
uled intervals averaging three to six months has been the goal of the overall clinical evaluation. Only patients with rest pain requiring revascularization or amputation, with severe pregangrenous changes necessitating urgent or emergent operation, and with ischemic tissue necrosis and ulceration were included. Emergency patients in whom limb loss without operation could not be predicted with relative certainty from available data, were eliminated from the study. The most important parameters in this review were number of procedures performed each year, age and sex distribution, types and frequency of procedures performed, From the Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC. Reprint requests should be addressed to George J. Collins, Jr, MD, LTC, MC, Peripheral Vascular Surgery Service, Department of Surgery, Walter Reed Army Medical Center, Washington, DC 20012. Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3-6, 1976.
Volume 132, December 1976
whether the procedure was a primary operation or reoperation, number and types of associated illnesses, amputation rates, and patency rates in the early postoperative period and at last follow-up. Results
During the period from 1965 to 1975, ninety patients (82 per cent males, 18 per cent females) had limb salvage procedures. Very few procedures were performed in the early years, whereas there has been a progressive increase in the number of cases each year since 1972 (19652; 1966,O; 1967,3; 1963,5; 1969, 1; 1970,6; 1971, 5; 1972, 8; 1973, 16; 1974, 21; 1975, 23). The average age of patients undergoing these procedures was fifty-seven years (range, 23 to 90 years). The indications for operation were rest pain in eight patients (8.9 per cent), ischemic necrosis and ulceration in twenty-six (28.9 per cent), and pregangrene in fifty-six (62.2 per cent). As outlined in Table I, there was a high incidence of associated or prior significant illnesses. Cardiovascular disease was the most common associated illness, occurring in 41.0 per cent of patients. The types of cardiovascular illnesses were prior myocardial infarction (14.4 per cent), congestive heart failure (10 per cent), hypertension (7.8 per cent), angina pectoris (4.4 per cent), and arrhythmia (4.4 per cent). Diabetes mellitus occurred in 22.2 per cent and thrombophlebitis occurred in 10 per cent of patients. As shown in Table II, sixteen types of procedures were performed. The most commonly performed operations were femoropoplitea1 bypass and aortofemoral bypass. In fifty-seven patients (63.3 per cent) the operation was primary and in thirty-three (36.7 per cent) the patient had had one or more previous vascular reconstructive procedures. Complications severe enough to prolong hospitalization, exclusive of amputations, occurred in eight patients (8.9 per cent), and the thirty day mortality rate was 8.9 per cent. Nine additional patients have died during the follow-up period. Patency was most commonly judged by palpable pulses or audible Doppler flow with improved ankle pressures. Postoperative arteriograms have been
707
Collins, Rich, and Andersen
TABLE
Illnesses in Limb Salvage Procedures
I Associated or Prior Significant Patients Undergoing (90 patients)
Cardiovascular disease Diabetes mellitus Thrombophlebitis Cerebrovascular accident Peptic ulcer disease Alcoholism Obstructive pulmonary disease Cancer Rheumatoid arthritis Pyoderma Infected prosthesis
II
Types and Frequency of Limb Salvage Procedures Performed Procedure
Number
Percentage
37 20 9 6 6 4 3 3 2 1 1
41.0 22.2 10.0 6.7 6.7 4.4 3.3 3.3 2.2, 1.1 1.1
performed in some patients. The early (less than 30 days) patency rate, exclusive of patients having expired and those having had sympathectomy only, was 79.7 per cent (63 of 79 were patent). At last follow-up, the adjusted patency rate (number patent/number alive) was 73.9 per cent @l/70). The amputation rate at thirty days was 14 per cent (13 patients) and only two surviving patients have had subsequent amputation, for an overall amputation rate of 16 per cent. Accurate recordings of both preoperative and postoperative ankle pressures were available in forty-nine patients. In considering affected vs unaffected limbs, the average preoperative ankle pressure, was 40.6 mm Hg in affected limbs and 124.5 mm Hg in unaffected limbs. At last follow-up the average ankle pressure was 115.0 mm Hg in previously affected limbs and 120.5 mm Hg in previously unaffected limbs. The difference between the mean preoperative ankle pressure in affected limbs and the mean ankle pressure in affected limbs at last follow-up was statistically significant (p
The results of this study indicate that operative attempts at lower extremity salvage are warranted in most patients. Although the complication rate of 8.9 per cent and the thirty day mortality rate of 8.9 per cent might be considered high, this must be contrasted with age-related mortality rates for amputation ranging from 7.9 to 16.4 per cent as reported by Kihn, Warren, and Beebe [1] and with the 11 per cent mortality rate cited by Mannick and Hume [2]. Our morbidity and mortality rates are comparable to those of other authors [3,4]. In a series of patients having femorotibial or femoroperoneal bypasses for extremity salvage, Jolly, Hill, and Herman [3] reported an early mortality rate of 4.8 per cent, with 24
708
TABLE
Number
Femoropopliteal bypass Aortofemoral bypass Extra-anatomic bypass Femoral thromboendarterectomy Aortopopliteal bypass Sympathectomy Femorotibial bypass Popliteal embolectomy Femoroprofundaplasty Popliteal thrombectomy Popliteal endarterectomy Aortoiliac endarterectomy Fasciotomy Femoroperoneal bypass Popliteal-tibia1 bypass Popliteal-popliteal bypass
26 19 12 10 3 3 3 2 2 2 2 2 1 1 1 1
per cent late deaths. Mortality rates ranging from 8 to 24 per cent were reported for high risk patients undergoing aortofemoral bypass for extremity salvage by Wesolowski et al [4]. Reichle and Tyson [5] have achieved rather low mortality rates in patients undergoing femoropopliteal (3.1 per cent) or femorotibial(2.9 per cent) bypass for limb salvage. Noon et al [6] have reported low in-hospital mortality rates (2.2 per cent) with distal bypass procedures for limb salvage. Mortality rate relates more to the preoperative condition of the patient than to the procedure performed. This has recently been emphasized by Freund, Romanoff, and Floman [7] who reported mortality rates after balloon catheter arterial embolectomy of 41 per cent. There is no sound basis for contesting the superiority of one procedure over another. As noted in Table II, the surgeon dealing with these types of patients must have at his disposal an armamentariurn comprised of many different procedures. The procedure must be tailored to the needs of each patient. It may be as simple as a fasciotomy, as in one of our patients with blunt trauma to the popliteal space, or as complex as an aortopopliteal bypass even though this procedure is frequently unsuccessful, as reported by Benson et al [8]. In general, success will be frequent if the most proximal obstruction is corrected first. In some cases, two procedures, such as an aortofemoral bypass combined with a femoropopliteal bypass or femorotibial bypass, may be necessary. This situation arises only infrequently and, in general, we have avoided simultaneous combined procedures. Extra-anatomic bypass procedures, such as axillofemoral bypass and femorofemoral bypass, have been a significant advancement,
The American Journal of Surgery
Lower Extremity lschemia
allowing one to perform frequently successful procedures with relatively low morbidity and mortality rates [g-11]. We have observed an increasing trend in our own practice to use such procedures for limb salvage in high risk patients. With the bulk of our experience being in recent years, our results do not reflect meaningful long-term patency rates. The early patency rate of 79.7 per cent and the patency rate at last follow-up of 72.9 per cent have encouraged us to attempt revascularization in almost all patients with limb-threatening ischemia. Only those with obviously far advanced gangrenous changes, those in whom the chance of success is negligible due to poor runoff, and those with severe associated diseases and marginal chances of success are considered for primary amputation. In these latter patients, a primary amputation might be considered less life-threatening than an extensive revascularization attempt soon to be followed by the associated morbidity and mortality of an amputation should the revascularization attempt fail. Summary Limb salvage procedures were performed in ninety patients during the period from 1965 to 1975. Sixteen different procedures were performed with an associated complication rate of 8.9 per cent and a mortality rate of 8.9 per cent. The patency rates were 79.7 per cent at thirty days and 72.9 per cent at last follow-up. References 1. Kihn FiB, Warren R, Beebe GW: The geriatric amputee. Ann Surg 176: 305, 1972. 2. Mannick JA. Hume DM: Salvage of extremities by vein grafts in far-advanced peripheral vascular disease. Surgery 155: 154,1964. 3. Jolly PC, Hill LD, Herman ML: Extremity salvage by small vessel revascularization. Am Surg 40: 521, 1974. 4. Wesolowski SA, Martinez A, Domingo RT, Fries CC, Schaefer HC. Sawyer PN, Gillie E, McMahon JD: Indications for aortofemoral arterial reconstruction: a study of borderline risk patients. Surgery 60: 288, 1966. 5. Reichle FA, Tyson RR: Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities. Ann Surg 18: 449, 1975. 6. Noon GP, Diethrich EB, Richardson WP, DeBakey ME: Distal tibia1 arterial bypass, analysis of 91 cases. Arch Surg 99:
Volume 132, December 1976
770, 1969. 7. Freund U, Romanoff l-t, Floman Y: Mortality rate following lower limb arterial embolectomy: causative factors. Surgery 77: 201,1975. 8. Benson JR, Whelan TJ, Cohen A, Spencer FC: Combined aorta-iliac and femoropopliteal occlusive disease: limitations of total aortofemoropopliteal bypass. Ann Surg 163: 121, 1966. 9. Moore WS, Hall AD, Blaisdell FW: Late results of axillaryfemoral bypass grafting. AmJSurg 122: 148, 1971. 10. Ayvazian VH, Auer Al, Hershey FB: Limb salvage by extended femorofemoral bypass. Surg Gynecol Of&et 135: 737, 1972. 11. Vetto RM: The femorofemoral shunt. An Appraisal. Am J Surg 112: 162.1966.
Discussion George Noon (Houston, TX): Did you use lumbar sympathectomy? Do you have a breakdown as to the acute or chronic nature of limb ischemia? I find preoperative arteriograms very valuable. If we stay in the femoral or popliteal artery above the knee, we can expect long-term patency with our grafts. However, even if the distal tibia1 bypass remains open only three to six months, it may save the limb by allowing healing of the skin ulcerations. I like to perform arteriography at operation to determine the state of distal circulation and to provide a basis for further surgery if necessary.
Falls B. Hershey (St. Louis, MO): I rise to compare our series of long vein grafts. These operations save legs but do not prolong life. We reported our first twenty-four cases at the Western Surgical Association some years ago and now have forty-five cases. These are elderly persons with gangrene of the toes or ischemic ulcers and widespread atherosclerosis. Mortality is high-15 per cent in the first month and 30 per cent in the first year. Operation was to avoid amputation. Only three legs were lost among the survivors. Twenty-five per cent of the survivors died of other causes, the graft being open. There were three late closures requiring amputation some years after operation. If the long grafts remain open a few months, the outlook is good. George J. Collins, Jr (closing): We have rarely used sympathectomy alone and have not performed concomitant sympathectomy for limb salvage. Results for the acute ischemia were very good. Patients with ischemic necrosis and ulceration had the worst sequelae. I concur that arteriograms are valuable, especially in diabetics and if distal bypass is being considered. We agree with Doctor Hershey that mortality depends more on the generalized atherosclerotic process.
709