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Limitations of peroneal artery bypass grafting for limb salvage
Limitations of peroneal artery bypass grafting for limb salvage Bruce M. Elliot-t, MD, Jacob G. Robison, MD, Thomas E. Brothers, MD, and Marshall A. Cross, MD, Charleston, S.C. Purpose: The purpose of this study was to compare the results of peroneal bypass grafting for limb salvage with the results of other tibial and pedal bypass grafts performed concurrently. Methods: Thirty-four peroneal bypass grafts with autologous vein were performed for limb salvage between September 1986 and June 1992. These constituted 18% o f an overall experience of 194 tibial or pedal bypasses performed during that time. Preoperative and intraoperative arteriograms were reviewed to identify anatomic characteristics associated with successful limb salvage. Results: Secondary patency rates for peroneal bypass grafts (70%) compared with the other tibial and pedal bypass grafts (65%) did not differ significantly at 48 months by life-table analysis. Limb salvage achieved by peroneal artery bypass grafting was significantly worse (55%) than that achieved by the remaining tibial and pedal bypasses (67%) at 48 months. Limb salvage was 33% at 7 months for those undergoing peroneal artery bypass grafting as opposed to 57% at 48 months for patients undergoing other tibial or pedal revascularizations with tissue necrosis. Four anatomic features were identified that were associated with failure after peroneal artery bypass grafting. These were peroneal length less than 10 cm (p = 0.012), peroneal artery diameter less than 2 mm (tO = 0.035), absence of arteriographically demonstrated collaterals perfusing the foot (p = 0.0001), and tittle or no visualization of the pedal arch (p = 0.008). Conclusions: Although successful grafts may avoid amputation in carefully selected cases, alternatives to peroneal artery bypass grafting should be considered when less than favorable anatomic conditions are encountered, particularly in the presence o f forefoot tissue necrosis. (J VASC SURG 1993;18:881-8.)
Peroneal artery bypass grafting is performed for limb salvage under a variety of circumstances, with variable results. Before the widespread application of pedal artery bypass grafting, peroneal artery bypass grafting constituted approximately 40% of tibial bypasses performed for limb salvage. 1,2 The peroneal artery is commonly the last tibial vessel in the leg to occlude with end-stage vascular disease, being the only available vessel for infrageniculate bypass in 37% of patients and the least diseased vessel in 40%. s,4 Despite this advanced degree of atheroscleFrom the Sectionof VascularSurgery,Departmentof Surgery, MedicalUniversityof South Carolina, Charleston. Presented at the SeventeenthAnnual Meeting of the Southern Association for Vascular Surgery,Fort Lauderdale,Fla., Jan. 28-31, 1993. Reprint requests: Bruce M. EUiott, MD, Section of Vascular Surgery,Departmentof Surgery,MedicalUniversityof South Carolina, 171 AshleyAve., Charleston,SC 29425-0901. Copyright © 1993 by The Society for Vascular Surgery and InternationalSocietyfor CardiovascularSurgery,North American Chapter. 0741-5214/93/$1.00 + .10 24/6/49636
rosis, reported patency rates of between 38% and 64% at 36 months, with accompanying limb-salvage rates of 68% to 81%, suggest comparable results after peroneal artery bypass grafting for limb salvage visa vis other distal bypassesfl ,s,4 Previous reports 14 have attempted to correlate various anatomic features associated with patency, but none have addressed the anatomic features associated with limb salvage, the ultimate goal of lower extremeity revascularization. This study was undertaken to review a &year experience with peroneal artery bypass grafting for limb salvage and compare its results with those of a larger group of tibial and pedal bypass grafts performed concurrently. MATERIAL AND M E T H O D S Between September 1986 and June 1992, 34 peroneal, 49 anterior or posterior tibial, and 111 pedal artery bypass grafting procedures (at or distal to the malleolus) were performed with autologous vein. Every attempt was made to establish direct 881
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Table III. Characteristics of peroneal arteries associated with limb salvage
Table I. Characteristics of patients undergoing infrageniculate bypass for limb salvage
Age (yr)
Characterirtic
Peroneal (n = 34)
Other (n = 160)
p Value
69.2 + 2*
67.4 _+ 0.8*
NS
15 19
112 48
0.004
8 12 14
35 63 57
NS
20 14
93 67
NS
16 18
90 70
NS
18 16
71 89
NS
Sex (n) Male Female Smoking (n) Never Former Current Diabetes (n) Yes No Rest pain (n) Yes No Tissue necrosis (n) Yes No
Table II. Characteristics of peroneal arteries associated with patency Collateral vessels visualized (n) Patent Occluded Smoking (n) Patent Occluded Peroneal length (n) Patent
Occluded Peroneal diameter (n) Patent Occluded Pedal arch visualized (n) Patent Occluded Tissue necrosis (n) Patent Occluded End-stage renal disease (n) Patent Occluded Diabetes (n) Patent Occluded Sex (n) Patent Occluded
< 10 cm
_>10 cm
1 5 < 2 mm
20 8 -> 2 mm
0.012
4 7
17 6
0.035
21 5
0.0001
11 1
0.008
(n) Salvage Amputation Peroneal diameter
(n) Salvage Amputation Collaterals visualized (n) Salvage Amputation Pedal arch visualized (n) Salvage Amputation
No
Yes 0 8
No
Yes 10 12
Table IV. Patient characteristics not statistically associated with limb loss after peroneal bypass
NS, Not significant. *Standard error of the mean.
Characteristic
Peroneal length
p Value
No
Characteri~'c
Yes
p Value
2 6
24 2
0.0017
7 1 < 10 cm
0.0058
3 < 2 mm 8 3
19 7 -> 10 cm 23 5 >-2 m m 18 5
15 7
11 1
NS
11 5
15 3
NS
22 8
4 0
NS
9 5
17 3 Female 13 6
NS
3
Male 13 2
NS
End-stage renal disease (n) Salvage Amputation Diabetes (n) Salvage Amputation Smoking (n) Salvage Amputation Sex (n) Salvage Amputation
No
Yes
p Value
20 10
1 3
0.10
10 4
11 9
0.33
3 5 Male 11 4
18 8 Female 10 9
0.11 0.22
NS
NS
NS, Not significant.
pulsatile flow to the foot in patients with forefoot ischemic necrosis. Consequently, those undergoing peroneal bypass with forefoot necrosis did not have an anterior or posterior tibial artery in continuity to
the foot, had inadequate pedal vessels for bypass grafting, or lacked an adequate venous conduit to reach the foot. In contrast, patients with ischemic rest pain without necrosis underwent bypasses to the least diseased vessel. Preoperative and intraoperative arteriograms were reviewed for all patients undergoing peroneal artery bypass grafting to determine (1) the length and diameter of the peroneal artery, (2) whether the pedal arch was patent or partially occluded versus little or no angiographic visualization, s and (3) the presence or absence of named or unnamed vessels from the peroneal artery perfusing the foot. Operative notes were reviewed to determine the origin of the grafts and whether they were in situ, reversed, or composite autologous vein grafts. Grafts of prosthetic materi~_ls were excluded. Inpatient and outpatient charts were reviewed to determine the age, sex, indication for operation, presence or absence of end-stage renal
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Fig. 1. Life-table analysis demonstrates primary patency rate (67%; SEM 9.7% at 48 months). Secondary patency (70%; SEM 9.4% at 48 months) and limb salvage rates (55%; SEM 9.6% at 48 months) associated with peroneal artery bypass grafts.
disease requiring dialysis, diabetes meUitus, and smoking history. Graft patency was determined by maintenance of an ankle/brachia] index greater than 0.15 over preoperative values, color-flow duplex scanning, or arteriography when graft compromise was suspected. Limb salvage was determined to be successful if major amputation above the ankle was avoided. Statistical comparisons were performed with the BMDP statistical software package (BMDP Statistica] Software Inc., Los Angeles, Calif.). Differences among groups were determined by analysis of variance for continuous variables. Univariate and multivariate analysis was used to check for statistically significant associations with graft patency or limb salvage. Associations between discreet variables were analyzed with two-way contingency tables, and statistical significance was determined by the Pearson ×2 test and Fisher exact test. Life-table analysis was performed, and differences in patency rates or limb salvage rates according to the type of bypass procedure performed were determined by a generalized Wilcoxon (Breslow) ranking. All p values < 0.05 were considered statistically significant. RESULTS Peroneal artery bypass grafting constituted 41% of all tibia] bypass grafting procedures performed
above the ankle but only 18% of all infrageniculate (tibia] and pedal) bypass grafting procedures performed. All 34 peronea] artery bypass grafting procedures were performed for limb salvage. The demographic characteristics of patients undergoing peroneal artery bypass grafting are listed in Table I. Fifty-six percent of these patients were women, which was significantly more than the proportionate number of women undergoing other tibia] or pedal bypass grafting procedures. Twenty-eight grafts originated from the common femora] artery, one from the superficial femora] artery, and five from the popliteal artery. Choice of inflow site was determined strictly by the absence of proximal hemodynamicaUy significant stenotic disease. Twenty-five grafting procedures were performed by the in situ technique, whereas eight used reversed saphenous vein and one required multiple composite veins for a suitable conduit. The choice of technique was determined on the basis of quality of the vein and its distal diameter as opposed to any specific preference. There was no significant association between site of inflow or technique of bypass and the resulting patency or limb salvage rates. Fifty-three percent of patients undergoing peronea] artery bypass grafting in this series had ischemic tissue necrosis, the indication for revascularization (category III, Committee on Reporting StandardsS).
884
JOURNAL OF VASCULAR SURGERY November 1993
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Fig. 2. Secondary patency rates for peroneal artery bypass grafts compared with remaining tibial and pedal grafts by life-table analysis. Secondary patency rates of 70% for peroneal (SEM 9.4% at 48 months) compared with tibial and pedal grafts of 65% (SEM 5.6% at 48 months) did not differ significantly (p = 0.45). Thirteen major amputations were required, all occurring within the first 6 months. Six of these 13 amputations were performed in the presence of a patent graft, all in the setting of progressive forefoot necrosis despite revascularization. No extremity with forefoot necrosis was salvaged if the peroneal artery was less than 10 cm in length or 2 mm in diameter or there were no angiographically identifiable collateral vessels perfusing the foot. One late graft thrombosis occurred that did not result in limb loss. Three patients died within 30 days of surgery for a perioperative mortality rate of 9% compared with 1% for the 160 patients undergoing tibial or pedal reconstruction in the concurrent series. This was not significantly different. Table II shows the results ofunivariate analysis by contingency tables associated with graft patency to the peroneal arteries. Only the presence of named or unnamed collateral vessels from the peroneal artery perfusing the foot visualized arteriographically was significantly associated with graft patency. However, Table III shows the four characteristics that were significantly associated with limb salvage as opposed to patency. Both univariate and multivariate analysis demonstrated the presence of arteriographically demonstrated collateral arterial flow perfusing the foot to be the single most important variable in predicting
both graft patency and limb salvage as well. Other factors demonstrating significant impact on limb salvage included peroneal artery length in excess of 10 cm, peroneal artery diameter greater than or equal to 2 mm, and whether the pedal arch was only partially occluded or completely patent versus little or no visualization arteriographically (scoring of the pedal archS). Table IV delineates characteristics associated with either success or failure to achieve limb salvage after peroneal bypass grafting. The presence or absence of end-stage renal disease, diabetes, smoking, and male or female gender was not statistically associated with limb loss or salvage. A primary patency rate for peroneal artery bypass grafts at 48 months was 67%, and a secondary patency rate of 70% at 48 months was achieved with salvage of one thrombosed graft. This resulted in a limb salvage rate of 55% at 48 months (Fig. 1). The secondary patency rate of 70% for peroneal and 65% for the cohort of tibial and pedal bypasses was not significantly different (Fig. 2). Fig. 3, however, demonstrates a disparity in limb salvage rates between peroneal artery bypass (55%) and other tibial and pedal bypasses (67%) at 48 months. This was significant atp = 0.0176. Fig. 4 demonstrates a wider disparity in limb salvage rates in the smaller group of patients with
JOURNAL OF VASCULAR SURGERY Volume 18, Number 5
Elliott et al.
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Fig. 3. Limb-salvage rates achieved by tibial and pedal bypasses were superior at 48 months (67%; SEM 5.3% at 48 months) to those achieved by peroneal bypass grafts (55%; SEM 9.6% at 48 months) (p = 0.0176). forefoot ischemic tissue necrosis undergoing peroneal artery bypass grafting (18 patients) versus those undergoing either pedal or other tibial revascularizations (71 patients). By life-table analysis, only 33% of those undergoing peroneal artery bypass grafting achieved limb salvage at 7 months as opposed to 57% of other reconstructions at 48 months when forefoot tissue necrosis was evident. This was significant at p = 0.0496. DISCUSSION
The first "successful" peroneal artery bypass graft was reported with homograft in a total series of eight tibial level reconstructions. 6 The success of this first peroneal graft was measured in weeks and culminated in amputation at 6 weeks from thrombosis. These pioneering efforts led to today's accepted practice of tibial artery reconstruction for limb salvage. As techniques have improved, pedal bypass reconstruction is now commonplace7's and often performed under extreme circumstances with acceptable limb salvage rates in settings that not too many years ago would have resulted in amputation. This series reflects a very aggressive attitude toward revascularization of the threatened extremity, with 57% of all infrageniculate bypass grafts performed during the past 6 years done at the level of the pedal arteries. From the context of a very aggressive distal revascu-
larization experience, the results of more proximal peroneal artery bypass grafting were questioned, representing a change from 41% of all tibial bypass grafts in previous reports ~4 to 18% in this series. Several demographic, as well as techniquerelated, details had no significant impact on either graft patency or limb salvage. Diabetes was present in the majority of patients undergoing both peroneal artery bypass grafting and all other forms of infrageniculate bypass grafting in this series. This study fails to indicate that diabetes had any significant impact on long-term patency or limb salvage and is in agreement with others, s-14 In contrast to an expressed pessimism for revascularization in patients with end-stage renal disease and diabetes with ischemic ulceration) s,16 end-stage renal disease per se was not considered a contraindication to revascularization for limb salvage in this series. Prosthetic grafts or composite grafts with prosthetic materials were rarely used during the period of this study, reflecting an obligate vein utilization policy for infrageniculate revascularization, derived from the poor results in published trials3721 Very good results may be obtained under adverse conditions with a variety of techniques with autologous vein including arm vein. 22 Although controversy continues to exist concerning the preferred technique
886
JOURNAL OF VASCULAR SURGERY November 1993
Elliott et al. 71
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Fig. 4. Life-table analysis demonstrates limb salvage rates for those with tissue necrosis undergoing peroneal artery bypass grafting (33% at 7 months). SEM exceeded 10% at 3 months in this group. Tibial and pedal revascularization achieved limb-salvage rate of 57% at 48 months (SEM 7.6%). Difference was significant atp = 0.0496.
of in situ 2s'25 versus reversed vein bypass grafting,16,22,26 it appears that the results of the two techniques are quite sin'l~laro 27"29 Our experience suggests that the particular type of technique has little impact on long-term salvage or patency when employed in the peroneal position. Similarly, the choice of inflow site had no impact on the results ofperoneal bypass grafting, which is in agreement with other reports indicating that the grafts may originate from a distal site provided there is no proximal hemodynamically significant stenosis, s°ss Most would agree that sustained graft patency is an important component of limb salvage. Limb salvage rates tend to at least equal and may frequently exceed graft patency rates by approximately 10%, s'16,26,s4'ssdepending on whether tissue necrosis is present. This is in sharp contrast to the results of this study, which demonstrate an acceptable secondary patency rate for peroneal artery bypass grafting of 70% at 48 months but a much poorer limb salvage rate of only 55% at 48 months. This was the result of a large number of amputations (6 out of 13) despite a patent bypass graft with progressive forefoot necrosis and sepsis. In comparison, amputations performed with a patent bypass graft range from 8% in the setting of pedal grafts 7 to 17% in all tibial revascularizations. 36.39
Inferior limb salvage obtained after peroneal artery bypass grafting in this series compared with the larger cohort of patients undergoing other forms of tibial or pedal revascularization are readily apparent (Figs. 3 and 4). Four distinct anatomic features have been identified in this work that have helped to define realistic expectations for peroneal artery bypass grafting, particularly in the setting of forefoot tissue necrosis. The single strongest anatomic feature was the presence or absence of collaterals from the terminal peroneal artery perfusing the foot. No limb was salvaged in any patient who did not have arteriographically demonstrated collateral flow perfusing the foot. Other factors that negatively impacted on limb salvage, but not graft patency, were length of the peroneal artery less than 10 cm, diameter less than 2 mm, and little or no pedal arch visualizeds on arteriography. The results of this study would indicate that peroneal artery bypass grafting remains a viable alternative only when favorable anatomic features are present. In the presence of established forefoot tissue necrosis, better results were obtained with other forms of tibial or pedal revascularization that established direct pulsatile flow to the forefoot as opposed to the peroneal artery, which relied on terminal collateral flow.
JOURNAL OF VASCULARSURGERY Volume 18, Number 5
Inadequate arteriography may fail to visualize anatomic features favorable for limb salvage and mistakenly deem the extremity as "unreconstructible." High-quality arteriography, either selective intraarterial digital subtraction or conventional angiography with particular emphasis on the foot, is absolutely essential for operative planning and appropriate decision making. Liberal intraoperative and selected repeat arteriography must be employed if any concerns remain regarding the adequacy of the initial diagnostic arteriogram. In those situations in which direct reconstruction cannot be performed and several favorable anatomic features are absent on high-quality arteriography, primary amputation should strongly be considered if we are to avoid the most costly form of amputation (i.e., bypass grafting followed by amputation).40-42 With modern surgical techniques, we can now construct grafts to small diseased vessels that will remain patent but may not result in limb salvage. We must now look beyond the technical success of establishing a patent graft toward a clearer delineation of when futile attempts should be avoided and primary amputation considered. We acknowledge the assistance of Christopher Hannegan, PhD, in performing the statistical analysis. REFERENCES 1. Dardik H, Ibrahim IM, Dardik II. The role of the peroneal artery for limb salvage. Ann Surg 1979;189:189-98. 2. Graham JW, Hand KC. Vein grafts to the peroneal artery. Surgery 1981;89:264-7. 3. Shortell CK, Ouriel K, DeWeese JA, Green RM. Peroneal artery bypass: a multifactorial analysis. Ann Vase Surg 1992;6:15-9. 4. Karmody AM, Leather RP, Shah DM, Corson JD, Naraynsingh V. Peroneal artery bypass: a reappraisal of its value in limb salvage. J Vasc SURG 1984;1:809-16. 5. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischemia. J Vasc SURG 1986;4:80-94. 6. McCaughan JJ Jr. Successful arterial grafts to the anterior tibial, posterior tibial (below the peroneal), and peroneal arteries. Angiology 1961;12:91-4. 7. Harrington EB, Harrington ME, Schanzer H, Jacobson JH, Haimov M. The dorsalis pedis bypass: moderate success in difficult situations. J VASCSURG 1992;15:409-16. 8. Clifford EJ, Fry RE, Clagett GP, Fisher DF, Fry WJ. Results of in-situ saphenous vein bypass to the foot. Am J Surg 1989;158:502-5. 9. Taylor LM, Porter JM. The clinical course of diabetics who require emergent foot surgery because of infection or ischemia. J Vasc SURG 1987;6:454-9. 10. Shah DM, Chang BB, Fitzgerald KM, Kaufman JL, Leather RP. Durability of the tibial artery bypass in diabetic patients. Am J Surg 1988;156:133-5. 11. Pomposelli FB, Jepsen SJ, Gibbons GW, et al. Efficacy of the dorsal pedal bypass for limb salvage in diabetic pa-
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tients: short-term observations. J VASC SURG 1990;11: 745-52. 12. Tannenbaum GA, Pomposelli FB, Marcaccio EJ, et al. Safety of vein bypass grafting to the dorsal pedal artery in diabetic patients with foot infections. J VASe SURG 1992;15: 982-90. 13. LoGerfo FW, Gibbons GW, Pomposelli FB, et al. Trends in the care of the diabetic foot: expanded role of arterial reconstruction. Arch Surg 1992;127:617-21. 14. TaylorLM, Edwards JM, Porter JM. Present status ofreversed vein bypass grafting: five-year results of a modern series. J VASCSURG 1990;11:193-206. 15. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD): comparison of modern results in patients with and without ESRD. Arch Surg 1988;123:1164-8. 16. Taylor LM, Hamre D, Dalman ILL, Porter JM. Limb salvage vs amputation for critical ischemia: the role of vascular surgery. Arch Surg 1991;126:1251-8. 17. Rutherford RB, Jones DN, Bergentz SE, et al. Factors affecting the patency of infraingulnal bypass. J VASe SURG 1988;8:236-46. 18. Whittemore AD, Kent KC, Donaldson MC, Couch NP, Mannick JA. What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction. J VASC SURG 1989,10:299-305. 19. Dennis JW, Littooy FN, Greisler HP, Baker WH. Secondary vascular procedures with polytetrafluoroethylene grafts for lower extremity ischemia in a male veteran population. J VAsc SURG 1988;8:137-42. 20. Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infraingninal arterial reconstructions. J VAsc SURG 1986;3:104-14. 21. Fllnn WR, Rohrer MJ, Yao JS, McCarthy WJ, Fahey VA, Bergan JJ. Improved long-term patency of infragenicular polytetrafluoroethylene grafts. J VASCSUV.G1988;7:685-90. 22. Harward TR, Goe D, Flynn TC, Seeger JM. The use of arm vein conduits during infrageniculate arterial bypass. J VAsc SURG 1992;16:420-7. 23. Donaldson MC, Mannick JA, Whittemore AD. Femoraidistal bypass with in situ greater saphenous vein: long term results using the Mills valvulotome. Ann Surg 1991 ;213:45765. 24. Fogle MA, Whittemore AD, Couch NP, Mannick JA. A comparison of in situ and reversed saphenous vein grafts for infrainguinal reconstruction. J VAsc SURG 1987;5:46-52. 25. Buchbinder D, Rollins DL, Semrow CM, Schuler JJ, Meyer JP, Flanigan DP. In situ fibial reconstruction: state-of-the-art or passing fancy. Ann Surg 1988;207:184-8. 26. Mills JL, Taylor SM. Results ofinfrainguinal revascularization with reversed vein conduits: a modern control series. Ann Vasc Surg 1991;5:156-62. 27. Dalman RL, Taylor LM Jr. Basic data related to infrainguinal revascularization procedures. Ann Vasc Surg 1990;4:309-12. 28. Veterans Administration Cooperative Study Group 141. Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibial-peroneal revascularization. Arch Surg 1988;123:434-8. 29. Wengerter KR, Veith FJ, Gupta SK, et ai. Prospective randomized multicenter comparison of in situ and reversed vein infrapopllteal bypasses. J VAsc SURG 1991;13:189-99. 30. Bergamini TM, Towne JB, Bandyk DF, Seabrook GR, Schmitt DD. Experience with in situ saphenous vein bypasses
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during 1981 to 1989: determinant factors of long-term patency. J Vasc SURG 1991;13:137-49. Shah DM, Darling RC, Chang BB, Kaufman JL1, Fitzgerald KM, Leather RP. Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience. J VAsc SURG 1992;15:402-8. Marks J, King TA, Baele H, Rubin J, Marmen C. Poplitealto-distal bypass for limb-threatening ischemia. J VAsc SURG 1992;15:755-60. Rosenbloom MS, Walsh JJ, Schuler JJ, et al. Long-term resuks of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries. J VAsc SURG 1988;7:691-6. Reichman W, Nichols B, Toner J, Jenvey W, Sobel M. Strategies in the treatment of major tissue loss and gangrene: results of 100 consecutive vascular reconstructions. Ann Vasc Surg 1990;4:233-7. Dalsing MC, White JV, Yao JS, Podrazik R, Flinn WR, Bergan JJ. Infrapopliteal bypass for established gangrene of the forefoot or toes. J VAsc Suv,G 1985;2:669-77. Miller N, Dardik H., Wolodiger F, et al. Transmetatarsal amputation: the role of adjunctive revascularization. J VASC SURG 1991;13:705-11.
JOURNALOF VASCULARSURGERY November 1993
37. Buchbinder D, Rolins DL, Verta MJ, et al. Early experience with in situ saphenous vein bypass for distal arterial reconstruction. Surgery 1986;99:350-7. 38. Semel L, Bredenberg CE, Aust JC. Limb loss despite functioning distal bypass. J Cardiovasc Surg 1989;30:473-8. 39. Dietzek AM, Gupta SK, Kram HB, Wengerter KR, Veith FJ. Limb loss with patent infra-inguinal bypasses. Eur J Vasc Surg 1990;4:413-7. 40. Cheshire NJ, Wolfe JH, Noone MA, Davies L, Drummond M. The economics of femorocrural reconstruction for critical leg ischemia with and without autologous vein. J VAsc SURG 1992;15:167-75. 41. Raviola CA, Nichter LS, Baker JD, et al. Cost of treating advanced leg ischernia: bypass graft vs primary amputation. Arch Surg 1988;123:495-6. 42. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb threatening ischemia. Surgery 1985;90:2634. Submitted Feb. 10, 1993; accepted June 24, 1993.
DISCUSSION Dr. John Mannick (Boston, Mass.). You have presented evidence that suggests that vein grafts to the peroneal artery produce poorer results with respect to limb salvage than do vein grafts to the other tibial vessels. This result is at variance with other reports in the literature during the past 10 years and is also different from our own results. Our preference is to use in situ grafts to the tibial vessels whenever possible, and in a review in 1990 of an in situ vein graft series that includes 211 tibial vessel bypasses we found that the primary patency rate of 60 vein grafts to the peroneal artery was 74% at 3 years and 69% at 5 years. The secondary patency rate was 85% at 3- and 5-year intervals. We found that limb salvage after peroneal vein grafts was 94% at both 3 and 5 years. Both patency and limb salvage were numerically but not statistically superior for peroneal bypasses compared with bypasses to the anterior and posterior tibial arteries. H o w do we interpret these discrepancies? As you pointed out, the failures of the peroneal bypasses in your series came chiefly from vein grafts to isolated segments of peroneal artery, often less than 10 cm in length. Many surgeons, including ourselves, now believe that vein bypasses to short isolated tibial artery segments without direct connection to the foot are unlikely to be successful and such bypasses were ordinarily avoided in our own series. We believe, however, that the peroneal artery in general is the last artery to be preserved in many diabetic patients and is often a very satisfactory outflow conduit in such individuals, particularly if the artery ends normally in collaterals at the ankle and supplies the foot through a typical large collateral that proceeds into the foot anterior
to the lateral malleolus. On the other hand, in diabetic patients with complete distal occlusion of the peroneal artery, limb salvage seems more likely to result from a vein bypass to the dorsalis pedis or distal anterior tibial artery at the ankle, which is often preserved in the diabetic patient, or less often to the posterior tibial artery or its plantar extensions on the medial aspect of the foot. However, we would not preferentially perform a bypass to the dorsalis pedis artery in a diabetic patient if a normal peroneal artery were present as an outflow conduit because both calf and foot perfusion is restored by a bypass to the latter vessel. In this report you also demonstrate excellent results with respect to both patency and limb salvage when the vein grafts were placed in peroneal arteries with good connections to the foot. I believe, therefore, that the discrepancy between your results and the results of others including our own group is more apparent than real. Dr. Bruce M. Elliott. I think there are very few discrepancies between what you have said and what we are advocating. In truly dire circumstances, I think it is apparent that many vascular surgeons possess the techniques and skills to accomplish a bypass graft to very hostile environments, such as isolated segments, and in fact achieve patency. Perhaps what you have discovered before we recognized it was that, although we technically could establish the graft, it did not result in limb salvage, and what we tried to articulate is that there is more to it than the technical finesse of establishing a graft. What we really need to refocus our thinking on is that maybe we should be doing primary amputations in some of those patients.
Peroneal artery bypass grafting is performed for limb salvage under a variety of circumstances, with variable results. Before the widespread application of pedal artery bypass grafting, peroneal artery bypass grafting constituted approximately 40% of tibial bypasses performed for limb salvage. 1,2 The peroneal artery is commonly the last tibial vessel in the leg to occlude with end-stage vascular disease, being the only available vessel for infrageniculate bypass in 37% of patients and the least diseased vessel in 40%. s,4 Despite this advanced degree of atheroscleFrom the Sectionof VascularSurgery,Departmentof Surgery, MedicalUniversityof South Carolina, Charleston. Presented at the SeventeenthAnnual Meeting of the Southern Association for Vascular Surgery,Fort Lauderdale,Fla., Jan. 28-31, 1993. Reprint requests: Bruce M. EUiott, MD, Section of Vascular Surgery,Departmentof Surgery,MedicalUniversityof South Carolina, 171 AshleyAve., Charleston,SC 29425-0901. Copyright © 1993 by The Society for Vascular Surgery and InternationalSocietyfor CardiovascularSurgery,North American Chapter. 0741-5214/93/$1.00 + .10 24/6/49636
rosis, reported patency rates of between 38% and 64% at 36 months, with accompanying limb-salvage rates of 68% to 81%, suggest comparable results after peroneal artery bypass grafting for limb salvage visa vis other distal bypassesfl ,s,4 Previous reports 14 have attempted to correlate various anatomic features associated with patency, but none have addressed the anatomic features associated with limb salvage, the ultimate goal of lower extremeity revascularization. This study was undertaken to review a &year experience with peroneal artery bypass grafting for limb salvage and compare its results with those of a larger group of tibial and pedal bypass grafts performed concurrently. MATERIAL AND M E T H O D S Between September 1986 and June 1992, 34 peroneal, 49 anterior or posterior tibial, and 111 pedal artery bypass grafting procedures (at or distal to the malleolus) were performed with autologous vein. Every attempt was made to establish direct 881
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Elliott et al.
Table III. Characteristics of peroneal arteries associated with limb salvage
Table I. Characteristics of patients undergoing infrageniculate bypass for limb salvage
Age (yr)
Characterirtic
Peroneal (n = 34)
Other (n = 160)
p Value
69.2 + 2*
67.4 _+ 0.8*
NS
15 19
112 48
0.004
8 12 14
35 63 57
NS
20 14
93 67
NS
16 18
90 70
NS
18 16
71 89
NS
Sex (n) Male Female Smoking (n) Never Former Current Diabetes (n) Yes No Rest pain (n) Yes No Tissue necrosis (n) Yes No
Table II. Characteristics of peroneal arteries associated with patency Collateral vessels visualized (n) Patent Occluded Smoking (n) Patent Occluded Peroneal length (n) Patent
Occluded Peroneal diameter (n) Patent Occluded Pedal arch visualized (n) Patent Occluded Tissue necrosis (n) Patent Occluded End-stage renal disease (n) Patent Occluded Diabetes (n) Patent Occluded Sex (n) Patent Occluded
< 10 cm
_>10 cm
1 5 < 2 mm
20 8 -> 2 mm
0.012
4 7
17 6
0.035
21 5
0.0001
11 1
0.008
(n) Salvage Amputation Peroneal diameter
(n) Salvage Amputation Collaterals visualized (n) Salvage Amputation Pedal arch visualized (n) Salvage Amputation
No
Yes 0 8
No
Yes 10 12
Table IV. Patient characteristics not statistically associated with limb loss after peroneal bypass
NS, Not significant. *Standard error of the mean.
Characteristic
Peroneal length
p Value
No
Characteri~'c
Yes
p Value
2 6
24 2
0.0017
7 1 < 10 cm
0.0058
3 < 2 mm 8 3
19 7 -> 10 cm 23 5 >-2 m m 18 5
15 7
11 1
NS
11 5
15 3
NS
22 8
4 0
NS
9 5
17 3 Female 13 6
NS
3
Male 13 2
NS
End-stage renal disease (n) Salvage Amputation Diabetes (n) Salvage Amputation Smoking (n) Salvage Amputation Sex (n) Salvage Amputation
No
Yes
p Value
20 10
1 3
0.10
10 4
11 9
0.33
3 5 Male 11 4
18 8 Female 10 9
0.11 0.22
NS
NS
NS, Not significant.
pulsatile flow to the foot in patients with forefoot ischemic necrosis. Consequently, those undergoing peroneal bypass with forefoot necrosis did not have an anterior or posterior tibial artery in continuity to
the foot, had inadequate pedal vessels for bypass grafting, or lacked an adequate venous conduit to reach the foot. In contrast, patients with ischemic rest pain without necrosis underwent bypasses to the least diseased vessel. Preoperative and intraoperative arteriograms were reviewed for all patients undergoing peroneal artery bypass grafting to determine (1) the length and diameter of the peroneal artery, (2) whether the pedal arch was patent or partially occluded versus little or no angiographic visualization, s and (3) the presence or absence of named or unnamed vessels from the peroneal artery perfusing the foot. Operative notes were reviewed to determine the origin of the grafts and whether they were in situ, reversed, or composite autologous vein grafts. Grafts of prosthetic materi~_ls were excluded. Inpatient and outpatient charts were reviewed to determine the age, sex, indication for operation, presence or absence of end-stage renal
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Fig. 1. Life-table analysis demonstrates primary patency rate (67%; SEM 9.7% at 48 months). Secondary patency (70%; SEM 9.4% at 48 months) and limb salvage rates (55%; SEM 9.6% at 48 months) associated with peroneal artery bypass grafts.
disease requiring dialysis, diabetes meUitus, and smoking history. Graft patency was determined by maintenance of an ankle/brachia] index greater than 0.15 over preoperative values, color-flow duplex scanning, or arteriography when graft compromise was suspected. Limb salvage was determined to be successful if major amputation above the ankle was avoided. Statistical comparisons were performed with the BMDP statistical software package (BMDP Statistica] Software Inc., Los Angeles, Calif.). Differences among groups were determined by analysis of variance for continuous variables. Univariate and multivariate analysis was used to check for statistically significant associations with graft patency or limb salvage. Associations between discreet variables were analyzed with two-way contingency tables, and statistical significance was determined by the Pearson ×2 test and Fisher exact test. Life-table analysis was performed, and differences in patency rates or limb salvage rates according to the type of bypass procedure performed were determined by a generalized Wilcoxon (Breslow) ranking. All p values < 0.05 were considered statistically significant. RESULTS Peroneal artery bypass grafting constituted 41% of all tibia] bypass grafting procedures performed
above the ankle but only 18% of all infrageniculate (tibia] and pedal) bypass grafting procedures performed. All 34 peronea] artery bypass grafting procedures were performed for limb salvage. The demographic characteristics of patients undergoing peroneal artery bypass grafting are listed in Table I. Fifty-six percent of these patients were women, which was significantly more than the proportionate number of women undergoing other tibia] or pedal bypass grafting procedures. Twenty-eight grafts originated from the common femora] artery, one from the superficial femora] artery, and five from the popliteal artery. Choice of inflow site was determined strictly by the absence of proximal hemodynamicaUy significant stenotic disease. Twenty-five grafting procedures were performed by the in situ technique, whereas eight used reversed saphenous vein and one required multiple composite veins for a suitable conduit. The choice of technique was determined on the basis of quality of the vein and its distal diameter as opposed to any specific preference. There was no significant association between site of inflow or technique of bypass and the resulting patency or limb salvage rates. Fifty-three percent of patients undergoing peronea] artery bypass grafting in this series had ischemic tissue necrosis, the indication for revascularization (category III, Committee on Reporting StandardsS).
884
JOURNAL OF VASCULAR SURGERY November 1993
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Fig. 2. Secondary patency rates for peroneal artery bypass grafts compared with remaining tibial and pedal grafts by life-table analysis. Secondary patency rates of 70% for peroneal (SEM 9.4% at 48 months) compared with tibial and pedal grafts of 65% (SEM 5.6% at 48 months) did not differ significantly (p = 0.45). Thirteen major amputations were required, all occurring within the first 6 months. Six of these 13 amputations were performed in the presence of a patent graft, all in the setting of progressive forefoot necrosis despite revascularization. No extremity with forefoot necrosis was salvaged if the peroneal artery was less than 10 cm in length or 2 mm in diameter or there were no angiographically identifiable collateral vessels perfusing the foot. One late graft thrombosis occurred that did not result in limb loss. Three patients died within 30 days of surgery for a perioperative mortality rate of 9% compared with 1% for the 160 patients undergoing tibial or pedal reconstruction in the concurrent series. This was not significantly different. Table II shows the results ofunivariate analysis by contingency tables associated with graft patency to the peroneal arteries. Only the presence of named or unnamed collateral vessels from the peroneal artery perfusing the foot visualized arteriographically was significantly associated with graft patency. However, Table III shows the four characteristics that were significantly associated with limb salvage as opposed to patency. Both univariate and multivariate analysis demonstrated the presence of arteriographically demonstrated collateral arterial flow perfusing the foot to be the single most important variable in predicting
both graft patency and limb salvage as well. Other factors demonstrating significant impact on limb salvage included peroneal artery length in excess of 10 cm, peroneal artery diameter greater than or equal to 2 mm, and whether the pedal arch was only partially occluded or completely patent versus little or no visualization arteriographically (scoring of the pedal archS). Table IV delineates characteristics associated with either success or failure to achieve limb salvage after peroneal bypass grafting. The presence or absence of end-stage renal disease, diabetes, smoking, and male or female gender was not statistically associated with limb loss or salvage. A primary patency rate for peroneal artery bypass grafts at 48 months was 67%, and a secondary patency rate of 70% at 48 months was achieved with salvage of one thrombosed graft. This resulted in a limb salvage rate of 55% at 48 months (Fig. 1). The secondary patency rate of 70% for peroneal and 65% for the cohort of tibial and pedal bypasses was not significantly different (Fig. 2). Fig. 3, however, demonstrates a disparity in limb salvage rates between peroneal artery bypass (55%) and other tibial and pedal bypasses (67%) at 48 months. This was significant atp = 0.0176. Fig. 4 demonstrates a wider disparity in limb salvage rates in the smaller group of patients with
JOURNAL OF VASCULAR SURGERY Volume 18, Number 5
Elliott et al.
885
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Fig. 3. Limb-salvage rates achieved by tibial and pedal bypasses were superior at 48 months (67%; SEM 5.3% at 48 months) to those achieved by peroneal bypass grafts (55%; SEM 9.6% at 48 months) (p = 0.0176). forefoot ischemic tissue necrosis undergoing peroneal artery bypass grafting (18 patients) versus those undergoing either pedal or other tibial revascularizations (71 patients). By life-table analysis, only 33% of those undergoing peroneal artery bypass grafting achieved limb salvage at 7 months as opposed to 57% of other reconstructions at 48 months when forefoot tissue necrosis was evident. This was significant at p = 0.0496. DISCUSSION
The first "successful" peroneal artery bypass graft was reported with homograft in a total series of eight tibial level reconstructions. 6 The success of this first peroneal graft was measured in weeks and culminated in amputation at 6 weeks from thrombosis. These pioneering efforts led to today's accepted practice of tibial artery reconstruction for limb salvage. As techniques have improved, pedal bypass reconstruction is now commonplace7's and often performed under extreme circumstances with acceptable limb salvage rates in settings that not too many years ago would have resulted in amputation. This series reflects a very aggressive attitude toward revascularization of the threatened extremity, with 57% of all infrageniculate bypass grafts performed during the past 6 years done at the level of the pedal arteries. From the context of a very aggressive distal revascu-
larization experience, the results of more proximal peroneal artery bypass grafting were questioned, representing a change from 41% of all tibial bypass grafts in previous reports ~4 to 18% in this series. Several demographic, as well as techniquerelated, details had no significant impact on either graft patency or limb salvage. Diabetes was present in the majority of patients undergoing both peroneal artery bypass grafting and all other forms of infrageniculate bypass grafting in this series. This study fails to indicate that diabetes had any significant impact on long-term patency or limb salvage and is in agreement with others, s-14 In contrast to an expressed pessimism for revascularization in patients with end-stage renal disease and diabetes with ischemic ulceration) s,16 end-stage renal disease per se was not considered a contraindication to revascularization for limb salvage in this series. Prosthetic grafts or composite grafts with prosthetic materials were rarely used during the period of this study, reflecting an obligate vein utilization policy for infrageniculate revascularization, derived from the poor results in published trials3721 Very good results may be obtained under adverse conditions with a variety of techniques with autologous vein including arm vein. 22 Although controversy continues to exist concerning the preferred technique
886
JOURNAL OF VASCULAR SURGERY November 1993
Elliott et al. 71
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Fig. 4. Life-table analysis demonstrates limb salvage rates for those with tissue necrosis undergoing peroneal artery bypass grafting (33% at 7 months). SEM exceeded 10% at 3 months in this group. Tibial and pedal revascularization achieved limb-salvage rate of 57% at 48 months (SEM 7.6%). Difference was significant atp = 0.0496.
of in situ 2s'25 versus reversed vein bypass grafting,16,22,26 it appears that the results of the two techniques are quite sin'l~laro 27"29 Our experience suggests that the particular type of technique has little impact on long-term salvage or patency when employed in the peroneal position. Similarly, the choice of inflow site had no impact on the results ofperoneal bypass grafting, which is in agreement with other reports indicating that the grafts may originate from a distal site provided there is no proximal hemodynamically significant stenosis, s°ss Most would agree that sustained graft patency is an important component of limb salvage. Limb salvage rates tend to at least equal and may frequently exceed graft patency rates by approximately 10%, s'16,26,s4'ssdepending on whether tissue necrosis is present. This is in sharp contrast to the results of this study, which demonstrate an acceptable secondary patency rate for peroneal artery bypass grafting of 70% at 48 months but a much poorer limb salvage rate of only 55% at 48 months. This was the result of a large number of amputations (6 out of 13) despite a patent bypass graft with progressive forefoot necrosis and sepsis. In comparison, amputations performed with a patent bypass graft range from 8% in the setting of pedal grafts 7 to 17% in all tibial revascularizations. 36.39
Inferior limb salvage obtained after peroneal artery bypass grafting in this series compared with the larger cohort of patients undergoing other forms of tibial or pedal revascularization are readily apparent (Figs. 3 and 4). Four distinct anatomic features have been identified in this work that have helped to define realistic expectations for peroneal artery bypass grafting, particularly in the setting of forefoot tissue necrosis. The single strongest anatomic feature was the presence or absence of collaterals from the terminal peroneal artery perfusing the foot. No limb was salvaged in any patient who did not have arteriographically demonstrated collateral flow perfusing the foot. Other factors that negatively impacted on limb salvage, but not graft patency, were length of the peroneal artery less than 10 cm, diameter less than 2 mm, and little or no pedal arch visualizeds on arteriography. The results of this study would indicate that peroneal artery bypass grafting remains a viable alternative only when favorable anatomic features are present. In the presence of established forefoot tissue necrosis, better results were obtained with other forms of tibial or pedal revascularization that established direct pulsatile flow to the forefoot as opposed to the peroneal artery, which relied on terminal collateral flow.
JOURNAL OF VASCULARSURGERY Volume 18, Number 5
Inadequate arteriography may fail to visualize anatomic features favorable for limb salvage and mistakenly deem the extremity as "unreconstructible." High-quality arteriography, either selective intraarterial digital subtraction or conventional angiography with particular emphasis on the foot, is absolutely essential for operative planning and appropriate decision making. Liberal intraoperative and selected repeat arteriography must be employed if any concerns remain regarding the adequacy of the initial diagnostic arteriogram. In those situations in which direct reconstruction cannot be performed and several favorable anatomic features are absent on high-quality arteriography, primary amputation should strongly be considered if we are to avoid the most costly form of amputation (i.e., bypass grafting followed by amputation).40-42 With modern surgical techniques, we can now construct grafts to small diseased vessels that will remain patent but may not result in limb salvage. We must now look beyond the technical success of establishing a patent graft toward a clearer delineation of when futile attempts should be avoided and primary amputation considered. We acknowledge the assistance of Christopher Hannegan, PhD, in performing the statistical analysis. REFERENCES 1. Dardik H, Ibrahim IM, Dardik II. The role of the peroneal artery for limb salvage. Ann Surg 1979;189:189-98. 2. Graham JW, Hand KC. Vein grafts to the peroneal artery. Surgery 1981;89:264-7. 3. Shortell CK, Ouriel K, DeWeese JA, Green RM. Peroneal artery bypass: a multifactorial analysis. Ann Vase Surg 1992;6:15-9. 4. Karmody AM, Leather RP, Shah DM, Corson JD, Naraynsingh V. Peroneal artery bypass: a reappraisal of its value in limb salvage. J Vasc SURG 1984;1:809-16. 5. Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery/North American Chapter, International Society for Cardiovascular Surgery. Suggested standards for reports dealing with lower extremity ischemia. J Vasc SURG 1986;4:80-94. 6. McCaughan JJ Jr. Successful arterial grafts to the anterior tibial, posterior tibial (below the peroneal), and peroneal arteries. Angiology 1961;12:91-4. 7. Harrington EB, Harrington ME, Schanzer H, Jacobson JH, Haimov M. The dorsalis pedis bypass: moderate success in difficult situations. J VASCSURG 1992;15:409-16. 8. Clifford EJ, Fry RE, Clagett GP, Fisher DF, Fry WJ. Results of in-situ saphenous vein bypass to the foot. Am J Surg 1989;158:502-5. 9. Taylor LM, Porter JM. The clinical course of diabetics who require emergent foot surgery because of infection or ischemia. J Vasc SURG 1987;6:454-9. 10. Shah DM, Chang BB, Fitzgerald KM, Kaufman JL, Leather RP. Durability of the tibial artery bypass in diabetic patients. Am J Surg 1988;156:133-5. 11. Pomposelli FB, Jepsen SJ, Gibbons GW, et al. Efficacy of the dorsal pedal bypass for limb salvage in diabetic pa-
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tients: short-term observations. J VASC SURG 1990;11: 745-52. 12. Tannenbaum GA, Pomposelli FB, Marcaccio EJ, et al. Safety of vein bypass grafting to the dorsal pedal artery in diabetic patients with foot infections. J VASe SURG 1992;15: 982-90. 13. LoGerfo FW, Gibbons GW, Pomposelli FB, et al. Trends in the care of the diabetic foot: expanded role of arterial reconstruction. Arch Surg 1992;127:617-21. 14. TaylorLM, Edwards JM, Porter JM. Present status ofreversed vein bypass grafting: five-year results of a modern series. J VASCSURG 1990;11:193-206. 15. Edwards JM, Taylor LM Jr, Porter JM. Limb salvage in end-stage renal disease (ESRD): comparison of modern results in patients with and without ESRD. Arch Surg 1988;123:1164-8. 16. Taylor LM, Hamre D, Dalman ILL, Porter JM. Limb salvage vs amputation for critical ischemia: the role of vascular surgery. Arch Surg 1991;126:1251-8. 17. Rutherford RB, Jones DN, Bergentz SE, et al. Factors affecting the patency of infraingulnal bypass. J VASe SURG 1988;8:236-46. 18. Whittemore AD, Kent KC, Donaldson MC, Couch NP, Mannick JA. What is the proper role of polytetrafluoroethylene grafts in infrainguinal reconstruction. J VASC SURG 1989,10:299-305. 19. Dennis JW, Littooy FN, Greisler HP, Baker WH. Secondary vascular procedures with polytetrafluoroethylene grafts for lower extremity ischemia in a male veteran population. J VAsc SURG 1988;8:137-42. 20. Veith FJ, Gupta SK, Ascer E, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infraingninal arterial reconstructions. J VAsc SURG 1986;3:104-14. 21. Fllnn WR, Rohrer MJ, Yao JS, McCarthy WJ, Fahey VA, Bergan JJ. Improved long-term patency of infragenicular polytetrafluoroethylene grafts. J VASCSUV.G1988;7:685-90. 22. Harward TR, Goe D, Flynn TC, Seeger JM. The use of arm vein conduits during infrageniculate arterial bypass. J VAsc SURG 1992;16:420-7. 23. Donaldson MC, Mannick JA, Whittemore AD. Femoraidistal bypass with in situ greater saphenous vein: long term results using the Mills valvulotome. Ann Surg 1991 ;213:45765. 24. Fogle MA, Whittemore AD, Couch NP, Mannick JA. A comparison of in situ and reversed saphenous vein grafts for infrainguinal reconstruction. J VAsc SURG 1987;5:46-52. 25. Buchbinder D, Rollins DL, Semrow CM, Schuler JJ, Meyer JP, Flanigan DP. In situ fibial reconstruction: state-of-the-art or passing fancy. Ann Surg 1988;207:184-8. 26. Mills JL, Taylor SM. Results ofinfrainguinal revascularization with reversed vein conduits: a modern control series. Ann Vasc Surg 1991;5:156-62. 27. Dalman RL, Taylor LM Jr. Basic data related to infrainguinal revascularization procedures. Ann Vasc Surg 1990;4:309-12. 28. Veterans Administration Cooperative Study Group 141. Comparative evaluation of prosthetic, reversed, and in situ vein bypass grafts in distal popliteal and tibial-peroneal revascularization. Arch Surg 1988;123:434-8. 29. Wengerter KR, Veith FJ, Gupta SK, et ai. Prospective randomized multicenter comparison of in situ and reversed vein infrapopllteal bypasses. J VAsc SURG 1991;13:189-99. 30. Bergamini TM, Towne JB, Bandyk DF, Seabrook GR, Schmitt DD. Experience with in situ saphenous vein bypasses
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during 1981 to 1989: determinant factors of long-term patency. J Vasc SURG 1991;13:137-49. Shah DM, Darling RC, Chang BB, Kaufman JL1, Fitzgerald KM, Leather RP. Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience. J VAsc SURG 1992;15:402-8. Marks J, King TA, Baele H, Rubin J, Marmen C. Poplitealto-distal bypass for limb-threatening ischemia. J VAsc SURG 1992;15:755-60. Rosenbloom MS, Walsh JJ, Schuler JJ, et al. Long-term resuks of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries. J VAsc SURG 1988;7:691-6. Reichman W, Nichols B, Toner J, Jenvey W, Sobel M. Strategies in the treatment of major tissue loss and gangrene: results of 100 consecutive vascular reconstructions. Ann Vasc Surg 1990;4:233-7. Dalsing MC, White JV, Yao JS, Podrazik R, Flinn WR, Bergan JJ. Infrapopliteal bypass for established gangrene of the forefoot or toes. J VAsc Suv,G 1985;2:669-77. Miller N, Dardik H., Wolodiger F, et al. Transmetatarsal amputation: the role of adjunctive revascularization. J VASC SURG 1991;13:705-11.
JOURNALOF VASCULARSURGERY November 1993
37. Buchbinder D, Rolins DL, Verta MJ, et al. Early experience with in situ saphenous vein bypass for distal arterial reconstruction. Surgery 1986;99:350-7. 38. Semel L, Bredenberg CE, Aust JC. Limb loss despite functioning distal bypass. J Cardiovasc Surg 1989;30:473-8. 39. Dietzek AM, Gupta SK, Kram HB, Wengerter KR, Veith FJ. Limb loss with patent infra-inguinal bypasses. Eur J Vasc Surg 1990;4:413-7. 40. Cheshire NJ, Wolfe JH, Noone MA, Davies L, Drummond M. The economics of femorocrural reconstruction for critical leg ischemia with and without autologous vein. J VAsc SURG 1992;15:167-75. 41. Raviola CA, Nichter LS, Baker JD, et al. Cost of treating advanced leg ischernia: bypass graft vs primary amputation. Arch Surg 1988;123:495-6. 42. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb threatening ischemia. Surgery 1985;90:2634. Submitted Feb. 10, 1993; accepted June 24, 1993.
DISCUSSION Dr. John Mannick (Boston, Mass.). You have presented evidence that suggests that vein grafts to the peroneal artery produce poorer results with respect to limb salvage than do vein grafts to the other tibial vessels. This result is at variance with other reports in the literature during the past 10 years and is also different from our own results. Our preference is to use in situ grafts to the tibial vessels whenever possible, and in a review in 1990 of an in situ vein graft series that includes 211 tibial vessel bypasses we found that the primary patency rate of 60 vein grafts to the peroneal artery was 74% at 3 years and 69% at 5 years. The secondary patency rate was 85% at 3- and 5-year intervals. We found that limb salvage after peroneal vein grafts was 94% at both 3 and 5 years. Both patency and limb salvage were numerically but not statistically superior for peroneal bypasses compared with bypasses to the anterior and posterior tibial arteries. H o w do we interpret these discrepancies? As you pointed out, the failures of the peroneal bypasses in your series came chiefly from vein grafts to isolated segments of peroneal artery, often less than 10 cm in length. Many surgeons, including ourselves, now believe that vein bypasses to short isolated tibial artery segments without direct connection to the foot are unlikely to be successful and such bypasses were ordinarily avoided in our own series. We believe, however, that the peroneal artery in general is the last artery to be preserved in many diabetic patients and is often a very satisfactory outflow conduit in such individuals, particularly if the artery ends normally in collaterals at the ankle and supplies the foot through a typical large collateral that proceeds into the foot anterior
to the lateral malleolus. On the other hand, in diabetic patients with complete distal occlusion of the peroneal artery, limb salvage seems more likely to result from a vein bypass to the dorsalis pedis or distal anterior tibial artery at the ankle, which is often preserved in the diabetic patient, or less often to the posterior tibial artery or its plantar extensions on the medial aspect of the foot. However, we would not preferentially perform a bypass to the dorsalis pedis artery in a diabetic patient if a normal peroneal artery were present as an outflow conduit because both calf and foot perfusion is restored by a bypass to the latter vessel. In this report you also demonstrate excellent results with respect to both patency and limb salvage when the vein grafts were placed in peroneal arteries with good connections to the foot. I believe, therefore, that the discrepancy between your results and the results of others including our own group is more apparent than real. Dr. Bruce M. Elliott. I think there are very few discrepancies between what you have said and what we are advocating. In truly dire circumstances, I think it is apparent that many vascular surgeons possess the techniques and skills to accomplish a bypass graft to very hostile environments, such as isolated segments, and in fact achieve patency. Perhaps what you have discovered before we recognized it was that, although we technically could establish the graft, it did not result in limb salvage, and what we tried to articulate is that there is more to it than the technical finesse of establishing a graft. What we really need to refocus our thinking on is that maybe we should be doing primary amputations in some of those patients.