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Popliteal-to-Distal Bypass Grafts for Limb Salvage
Popliteal-to-Distal Bypass Grafts for Limb Salvage Robert Verhelst, MD, Michael Bruneau, MD, Anne-Lise Nicolas, MD, Rodolphe Frangi, MD, Gebrine El Khoury, MD, Philippe Noirhomme, MD, and Robert Dion, MD, Brussels, Belgium
From July 1989 to July 1994, a total of 44 popliteal-to-distal artery bypasses were performed in 36 patients (29 men and seven women, mean age 62 ± 10 years). These procedures accounted for 8.8% of all infrainguinal revascularizations performed during that period. Risk factors included diabetes in 33 patients (92%), smoking in 18 (50%), and coronary artery disease in 15 (42%). Prior to revascularization all patients were at risk of limb loss. Tissue necrosis was present in 31 cases (71%), ulceration in eight cases (18%), and rest pain in five cases (11%). Patency of the femoral and popliteal arteries was confirmed prior to surgery in all cases. Intraoperative percutaneous angioplasty of the superficial femoral artery was performed in three cases. Proximal anastomosis was made to the distal popliteal artery in all cases. A total of 52 distal anastomoses (eight sequential bypasses) were made on the following arteries: posterior tibial artery in 13 cases, anterior tibial artery in eight cases, peroneal artery in six cases, plantar artery in two cases, and dorsalis pedis artery in 21 cases. The greater saphenous vein was used as graft material in 42 cases (95%) and the lesser saphenous vein in two cases (5%). No patient died during hospitalization. Early bypass occlusion occurred in three cases (6.8%) and led to amputation in all cases. Secondary patency and limb salvage rates at 3 years calculated using the actuarial method were 74% and 82% respectively. Bypass thrombosis due to superficial femoral artery deterioration was not observed in any case. The present study indicates that popliteal-to-distal artery bypass is a simple, durable, and low-risk method of lower limb revascularization. Medium-term results are promising and support routine use of popliteal-to-distal artery bypass for limb salvage in patients without significant stenosis of the superficial femoral artery. (Ann Vasc Surg 1997;11:505-509.)
INTRODUCTION Due to the high incidence of occlusive disease of the superficial femoral artery (SFA), the proximal anastomosis of most infrainguinal revascularizations is made to the common femoral artery. However, if From the Service de Chirurgie Thoracique et CardioVasculaire, Cliniques Universitaires Saint-Luc, Universite´ Catholique de Louvain, Bruxelles, Belgique. Presented at the Annual Meeting of the Societe´ de Chirurgie Vasculaire de Langue Franc¸aise, Bruges, Belgium, June 1-3, 1995. Correspondence to: R. Verhelst, MD, Service de Chirurgie Thoracique et Cardio-Vasculaire, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, B-1200 Bruxelles, Belgium.
the femoropopliteal axis is without significant narrowing as is often the case in diabetic patients, proximal anastomosis can be made to the popliteal artery. The advantages of popliteal-to-distal bypass (PDB) are to shorten the length of the bypass, save graft material, and avoid dissection of the inguinal region which is frequently associated with wound complications. The long-term risk of impaired patency due to deterioration of the SFA is controversial.
PATIENTS AND METHODS We retrospectively evaluated 44 PDB procedures performed on 36 patients during the period from 505
506
Verhelst et al.
July 1989 to July 1994. These procedures accounted for 8.8% of the 520 infrainguinal revascularizations carried out in our department during the same period. There were 29 men (80%) and six women (20%). Mean age was 62 years with a range from 29 to 78 years. Thirty-three patients were diabetic (92%). Fifteen patients (42%) had coronary artery disease. Eighteen patients (50%) were smokers. Eighteen patients (50%) presented with poorly controlled hypertension. Four patients were on chronic dialysis. Prior to revascularization all patients were at risk of limb loss. Infected foot gangrene was noted in 31 cases (71%), ischemic ulceration in eight cases (18%), and rest pain in five cases (11%). The mean value of transcutaneous oxygen measurements, which were made whenever technically possible, (30 cases) was 18 ± 7 mmHg. Arteriography included opacification of the aortoiliac junction according to the Seldinger technique with selective injection of the ischemic limb at the level of the common femoral artery. The femoropopliteal trunk was patent in all cases and lesion-free in 39 cases. In two cases, a short narrowing involving more than 30% of lumen of the SFA was found and successfully treated by intraoperative percutaneous angioplasty. In three cases, narrowing of the SFA was less than 30% and was not treated. Occlusion of the three tibial arteries was present in 39 cases (89%). Revascularization was performed under locoregional anesthesia in 38 cases and under general anesthesia in six cases. The graft material was the ipsilateral greater saphenous vein (GSV) in 42 cases and the lesser saphenous vein (LSV) in two cases. The GSV was placed in the reversed fashion in 36 cases and in the nonreversed fashion after valvulotomy in six cases. The surgical technique was chosen in order to achieve optimal congruity at the proximal anastomosis. In one case, several vein segments were assembled end-to-end in order to obtain a sufficiently long graft. The proximal anastomosis was always made end-to-side to the lower popliteal artery using 6/0 polypropylene suture (Prolene, Ethicon, Johnson & Johnson, B-1710 Dilbeek). The distal anastomosis was made end-to-side to the largest patent artery of the leg or foot using 7/0 or 8/0 polypropylene. Whenever possible in patients with infected gangrene, an additional vein graft was placed from the first vein graft to a second artery supplying the area including the lesions (usually the dorsalis pedis artery) in order to optimize healing. Since this sequential bypass technique was used in eight cases, the total of distal anastomoses was 52. The locations of distal anasto-
Annals of Vascular Surgery
Table I. Location of distal anastomosis Posterior tibial artery Middle third Distal third Anterior tibial artery Middle third Distal third Peroneal artery Middle third Distal third Dorsalis pedis artery External plantar artery Total
13 4 9 10 5 5 6 4 2 21 2 52*
*Including 8 sequential grafts.
mosis are listed in Table 1. Tunneling of the bypass was performed as anatomically as possible. Bypasses to the anterior tibial artery or the dorsalis pedis artery were routed through the interosseous membrane. Bypasses with distal anastomosis to the peroneal artery were always placed through a medial leg incision. Graft patency was routinely controlled intraoperatively. In 34 cases, arteriography was performed by direct puncture of the bypass below the proximal anastomosis. In the remaining 10 cases, flowmetry was performed (Transonic System HT 107). All patients stayed at least 24 hours in the intensive care unit. During the first year of follow-up, duplex scanning was performed every 3 months. Thereafter, continuous Doppler examination was performed at the same interval. If impaired patency of the PDB was suspected, duplex scanning was performed. Immediate and late patency as well as limb salvage rate were calculated using the actuarial method in conformity with the guidelines proposed by the Ad Hoc Committee on Reporting Standards in 1986.1
RESULTS No patient died during the procedure or the immediate postoperative period. The mean duration of hospitalization was 29 days. Postoperative complications included myocardial infarction in one case, crescendo angina in three cases treated successfully with nitrates, and pulmonary edema in one case. Early occlusion of the PDB occurred in three cases: two on the 1st postoperative day and one on the 3rd postoperative day. Surgical thrombectomy was attempted in two of these patients and failed and below-knee amputation was required in all three
Vol. 11, No. 5, 1997
Fig. 1. Primary patency curve calculated using the acturarial method. The number of bypasses at risk at the beginning of each interval is indicated above the horizontal axis.
cases. These patients presented diffuse, distal arterial disease associated with end-stage renal disease in two cases and thromboangeitis obliterans in one case. In the remaining 33 patients in whom 41 PDB were patent, complete healing of skin lesions was obtained by the time of discharge. Mean transcutaneous oxygen tension measured on the forefoot 21 days after the procedure was 60 ± 9 mmHg (versus 18 ± 7 mmHg preoperatively). In addition to revascularization, 46 surgical procedures were performed during the same period of hospitalization. These procedures were preoperative drainage of purulent collections in nine cases, amputation of one or more toes in 28 cases, transmetatarsal amputation in seven cases, re-operation of the surgical wound in one case, placement of a pedunculated skin flap on the heel in one case, and placement of a free flap using the latissimus dorsi muscle on the forefoot in one case. The mean duration of follow-up was 27 months (range 1 to 65 months). Late occlusion occurred at 5, 11, 17, 32, 35, and 41 months in six of the 33 patients with the 41 patent PDB. Amputation was required in four of these patients. In two cases, graft occlusion led not to recurrence of critical ischemia. Occlusion was never due to development of stenosis in the SFA or popliteal artery. In three cases, repeat surgery was required at 4, 7, and 41 months to re-establish or maintain patency of the PDB. In one of these cases, external compression of a sequential bypass led to thrombosis with subacute ischemia that was successfully treated by fibrinolysis. In the other two cases requiring reoperation, Doppler examination demonstrated hemodynamic changes but there were no symptomatic manifestations. In both cases, the PDB was prolonged distally
Popliteal-to-distal bypass grafts for limb salvage 507
Fig. 2. Secondary patency curve calculated using the actuarial method. The number of bypasses at risk at the beginning of each interval is indicated above the horizontal axis.
Fig. 3. Limb salvage curve calculated using the actuarial method. The number of limbs at risk at the beginning of each interval is indicated above the horizontal axis.
because of anastomatic stenosis of the anastomosis in one case and deterioration of runoff in the other. Development of new stenosis in the SFA or popliteal artery was never observed during follow-up. Occlusion of the PDB was not observed in any of the patients who presented preoperative lesions of the SFA (treated or not) and all preexisting lesions remained stable. Amputation was not required in any patient with a patent PDB. Primary graft patency (Fig. 1) was 83% at 1 year, 70.8% at 3 years, and 61.3% at 5 years. Secondary patency (Fig. 2) was 87.3% at 1 year, 74.0% at 3 years, and 69.0% at 5 years and the corresponding limb salvage rates (Fig. 3) were 90.0%, 82.0%, and 77.4%, respectively. There were four deaths during follow-up due to heart disease in three cases and cancer in one case. Of the four patients who were on chronic di-
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alysis, two died of myocardial infarction and one required major amputation.
DISCUSSION Until now, PDB has been shunned due to the putative medium- and long-term risk of loss or impairment of graft patency related to development of lesions in the SFA.2,3 However, this theoretical risk has not been borne out in practice. Wengerter et al.4 reported a series of 153 PDB in which late patency was 60% at 5 years. This rate is comparable with that achieved with bypasses originating from the common femoral artery. Medium-term patency was not significantly lower when PDB was performed downstream from SFA presenting untreated stenosis less than 35% or stenosis greater than 35% after successful preoperative balloon angioplasty. In contrast, untreated stenosis greater than 35% was associated with lower 2-year patency although this difference was not statistically significant. Our experience, albeit limited, confirms these findings. In the three patients presenting stenosis involving less than 30% of the lumen of the SFA, no progression was noted in the narrowing and the PDB were patent after 30, 39, and 42 months. The two lesions treated by balloon angioplasty showed no sign of restenosis. Development of new lesions in the SFA or popliteal artery was not detected during follow-up in any patient including those in whom thrombosis of the PDB occurred. None of the three re-interventions required to maintain graft patency involved the proximal arterial tree. Based on these observations it appears reasonable to assume that proximal anastomosis on the SFA or popliteal artery is safe provided that any reduction in the lumen of the artery is less than 30%. In cases of stenosis greater than 30%, careful evaluation is necessary to determine the indication for balloon angioplasty, which can be highly effective.5,6 Short, concentric lesions with no calcification can be confidently treated by balloon angioplasty, thus extending the indications for PDB. As described elsewhere,4,7-9 PDB is simple and quick to perform and less invasive for the patient. These advantages probably account for the low mortality rates reported in previous series: 0% by Rosenbloom et al.,8 0.8% by Stonebridge et al.,7 and 3.9% by Wengerter et al.4 In the present study there were no perioperative deaths. However, it should be noted that the mean age in our series was 62 years due to the high proportion of young diabetics. In this regard it should also be underlined that diabetic arterial disease often involves distal arteries without major upstream occlusion.10
Annals of Vascular Surgery
Another advantage of PDB is that it requires a short graft segment so that revascularization is feasible even in patients with limited vein graft availability. In two patients in the present series PDB was performed using the LSV because GVS was unavailable. In patients with full vein graft availability the surgeon can choose the most suitable piece of vein in terms of quality and size. Given the importance of graft quality in determining patency,11,12 this freedom of choice could be a major factor in the excellent outcome of PDB. In our series, graft quality was always optimal and thrombosis due to vein graft defects was not observed. Use of PDB also economizes substitute material for subsequent reconstruction if necessary. In most cases (86% in the present series), the GVS is placed in the reversed position because of the similar diameter of its malleolar and popliteal segments. This configuration avoids uncommon but well-documented complications of the in situ bypass technique related to valvulotomy and persistent arteriovenous fistula.13,14 Use of PDP also limits the number of skin incisions and avoids dissection of the inguinal region, which is a frequent cause of wound complications. In our series, localized, superficial disunion of the surgical incision occurred in only one case. This is in sharp contrast with the high incidence of wound complications varying from 17% to 44%, reported in series using the conventional in situ bypass technique.15-17 Because of their short length, PDB have better hemodynamics than longer grafts. In a retrospective study published in 1988, Ascer et al.18 showed that patency of short bypass was better than that of long bypasses especially when the outflow tract was poor. The fact that PDB originating from the infragenicular popliteal artery are not submitted to joint movement could also be an advantage. Infected tissue necrosis was present in 71% of the limbs revascularized in this series. Like other authors19,20 we attempted to promote healing by re-establishing flow to an artery in direct connection with the skin lesions. For the same reason we also performed sequential bypass whenever possible in these patients. Using this direct revascularization approach, prompt spontaneous healing of lesions was obtained in all cases. The fact that rapid healing was also achieved in the eight cases in which sequential bypass was performed supports the use of this aggressive approach. Secondary patency in our series was at 74% at 3 years and 69% at 5 years. Although follow-up is limited, these rates compare favorably with those obtained using conventional methods.21 Limb salvage rates were 82% at 3 years and 77% at 5 years.
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Given the severity of the preoperative lesions these results are encouraging and justify continued use of this aggressive approach. Based on our experience, PDB appears to have numerous advantages that justify its routine use for limb salvage in patients without significant stenosis of the femoropopliteal axis.
Popliteal-to-distal bypass grafts for limb salvage 509
10. 11.
12.
REFERENCES 1. Rutherford RB, Flanigan DP, Gupta SK, et al. 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. 2. Kuthan F, Burkhalter A, Baitsch R, et al. Development of occlusive arterial disease in lower limbs. Arch Surg 1971; 103:545-561. 3. Auer AL, Hershey FB. Bypass vein grafts to distal tibial or dorsalis pedis arteries. Mo Med 1973;70:93-100. 4. Wengerter KR, Yang PM, Veith FJ, et al. A twelve-year experience with the popliteal-to-distal artery bypass: The significance and management of proximal disease. J Vasc Surg 1992;15:143-151. 5. Gallino A, Mahler F, Probst P, Nachbur B. Percutaneous transluminal angioplasty of the arteries of the lower limbs: A 5-year follow-up. Circulation 1984;70:619-623. 6. Stokes KR, Strunk HM, Campbell DR, et al. Five-year results of iliac and femoropopliteal angioplasty in diabetic patients. Radiology 1990;174:977-982. 7. Stonebridge PA, Tsoukas AI, Pomposelli FB, et al. Poplitealto-distal bypass grafts for limb salvage in diabetics. Eur J Vasc Surg 1991;5:265-269. 8. Rosenbloom MS, Walsh JJ, Schuler JJ, et al. Long-term results of infragenicular bypasses with autogenous vein originating from the distal superficial femoral and popliteal arteries. J Vasc Surg 1988;7:691-696. 9. Marks J, King TA, Baele H, et al. Popliteal-to-distal bypass
13.
14.
15.
16.
17.
18.
19.
20.
21.
for limb-threatening ischemia. J Vasc Surg 1992;15:755760. Haimovici H. Patterns of atherosclerotic lesions of the lower extremity. Arch Surg 1967;95:918-933. Bergamini TM, Towne JB, Bandyk DF, et al. Experience with in situ saphenous vein bypasses during 1981 to 1989: Determinant factors of long-term patency. J Vasc Surg 1991; 13:137-149. Rutherford RB, Jones DN, Bergentz SE, et al. Factors affecting the patency of infrainguinal bypass. J Vasc Surg 1988;8: 236-246. Gannon MX, Goldman MD, Simms MH, et al. Perioperative complications of in-situ vein bypass. Ann R Coll Surg Engl 1986;68:134-136. Donaldson MC, Mannick JA, Whittemore AD. Causes of primary graft failure after in situ saphenous vein bypass grafting. J Vasc Surg 1992;15:113-120. Reifsnyder T, Bandyk D, Seabrook G, et al. Wound complications of the in situ saphenous vein bypass technique. J Vasc Surg 1992;11:843-810. Wengrovitz M, Atnip RG, Gifford RRM, et al. Wound complications of autogeneous subcutaneous infrainguinal arterial bypass surgery: Predisposing factors and management. J Vasc Surg 1990;11:116-163. Rhodes GR, Skudder P. Salvage of ischemic diabetic feet: Role of transcutaneous oxygen mapping and multiple configurations of in situ bypass. Am J Surg 1986;152:161-171. Ascer E, Veith FJ, Gupta SK, et al. Short vein grafts: A superior option for arterial reconstructions to poor or compromised outflow tracts. J Vasc Surg 1988;7:370-378. 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 Vasc Surg 1992;15:982-990. Pomposelli FB, Marcaccio EJ, Gibbons GW, et al. Dorsalis pedis arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes mellitus. J Vasc Surg 1991;21:371384. Shah DM, Darling C, Chang BB, et al. Is long vein bypass from groin to ankle a durable procedure? An analysis of a ten-year experience. J Vasc Surg 1992;15:402-408.
From July 1989 to July 1994, a total of 44 popliteal-to-distal artery bypasses were performed in 36 patients (29 men and seven women, mean age 62 ± 10 years). These procedures accounted for 8.8% of all infrainguinal revascularizations performed during that period. Risk factors included diabetes in 33 patients (92%), smoking in 18 (50%), and coronary artery disease in 15 (42%). Prior to revascularization all patients were at risk of limb loss. Tissue necrosis was present in 31 cases (71%), ulceration in eight cases (18%), and rest pain in five cases (11%). Patency of the femoral and popliteal arteries was confirmed prior to surgery in all cases. Intraoperative percutaneous angioplasty of the superficial femoral artery was performed in three cases. Proximal anastomosis was made to the distal popliteal artery in all cases. A total of 52 distal anastomoses (eight sequential bypasses) were made on the following arteries: posterior tibial artery in 13 cases, anterior tibial artery in eight cases, peroneal artery in six cases, plantar artery in two cases, and dorsalis pedis artery in 21 cases. The greater saphenous vein was used as graft material in 42 cases (95%) and the lesser saphenous vein in two cases (5%). No patient died during hospitalization. Early bypass occlusion occurred in three cases (6.8%) and led to amputation in all cases. Secondary patency and limb salvage rates at 3 years calculated using the actuarial method were 74% and 82% respectively. Bypass thrombosis due to superficial femoral artery deterioration was not observed in any case. The present study indicates that popliteal-to-distal artery bypass is a simple, durable, and low-risk method of lower limb revascularization. Medium-term results are promising and support routine use of popliteal-to-distal artery bypass for limb salvage in patients without significant stenosis of the superficial femoral artery. (Ann Vasc Surg 1997;11:505-509.)
INTRODUCTION Due to the high incidence of occlusive disease of the superficial femoral artery (SFA), the proximal anastomosis of most infrainguinal revascularizations is made to the common femoral artery. However, if From the Service de Chirurgie Thoracique et CardioVasculaire, Cliniques Universitaires Saint-Luc, Universite´ Catholique de Louvain, Bruxelles, Belgique. Presented at the Annual Meeting of the Societe´ de Chirurgie Vasculaire de Langue Franc¸aise, Bruges, Belgium, June 1-3, 1995. Correspondence to: R. Verhelst, MD, Service de Chirurgie Thoracique et Cardio-Vasculaire, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, B-1200 Bruxelles, Belgium.
the femoropopliteal axis is without significant narrowing as is often the case in diabetic patients, proximal anastomosis can be made to the popliteal artery. The advantages of popliteal-to-distal bypass (PDB) are to shorten the length of the bypass, save graft material, and avoid dissection of the inguinal region which is frequently associated with wound complications. The long-term risk of impaired patency due to deterioration of the SFA is controversial.
PATIENTS AND METHODS We retrospectively evaluated 44 PDB procedures performed on 36 patients during the period from 505
506
Verhelst et al.
July 1989 to July 1994. These procedures accounted for 8.8% of the 520 infrainguinal revascularizations carried out in our department during the same period. There were 29 men (80%) and six women (20%). Mean age was 62 years with a range from 29 to 78 years. Thirty-three patients were diabetic (92%). Fifteen patients (42%) had coronary artery disease. Eighteen patients (50%) were smokers. Eighteen patients (50%) presented with poorly controlled hypertension. Four patients were on chronic dialysis. Prior to revascularization all patients were at risk of limb loss. Infected foot gangrene was noted in 31 cases (71%), ischemic ulceration in eight cases (18%), and rest pain in five cases (11%). The mean value of transcutaneous oxygen measurements, which were made whenever technically possible, (30 cases) was 18 ± 7 mmHg. Arteriography included opacification of the aortoiliac junction according to the Seldinger technique with selective injection of the ischemic limb at the level of the common femoral artery. The femoropopliteal trunk was patent in all cases and lesion-free in 39 cases. In two cases, a short narrowing involving more than 30% of lumen of the SFA was found and successfully treated by intraoperative percutaneous angioplasty. In three cases, narrowing of the SFA was less than 30% and was not treated. Occlusion of the three tibial arteries was present in 39 cases (89%). Revascularization was performed under locoregional anesthesia in 38 cases and under general anesthesia in six cases. The graft material was the ipsilateral greater saphenous vein (GSV) in 42 cases and the lesser saphenous vein (LSV) in two cases. The GSV was placed in the reversed fashion in 36 cases and in the nonreversed fashion after valvulotomy in six cases. The surgical technique was chosen in order to achieve optimal congruity at the proximal anastomosis. In one case, several vein segments were assembled end-to-end in order to obtain a sufficiently long graft. The proximal anastomosis was always made end-to-side to the lower popliteal artery using 6/0 polypropylene suture (Prolene, Ethicon, Johnson & Johnson, B-1710 Dilbeek). The distal anastomosis was made end-to-side to the largest patent artery of the leg or foot using 7/0 or 8/0 polypropylene. Whenever possible in patients with infected gangrene, an additional vein graft was placed from the first vein graft to a second artery supplying the area including the lesions (usually the dorsalis pedis artery) in order to optimize healing. Since this sequential bypass technique was used in eight cases, the total of distal anastomoses was 52. The locations of distal anasto-
Annals of Vascular Surgery
Table I. Location of distal anastomosis Posterior tibial artery Middle third Distal third Anterior tibial artery Middle third Distal third Peroneal artery Middle third Distal third Dorsalis pedis artery External plantar artery Total
13 4 9 10 5 5 6 4 2 21 2 52*
*Including 8 sequential grafts.
mosis are listed in Table 1. Tunneling of the bypass was performed as anatomically as possible. Bypasses to the anterior tibial artery or the dorsalis pedis artery were routed through the interosseous membrane. Bypasses with distal anastomosis to the peroneal artery were always placed through a medial leg incision. Graft patency was routinely controlled intraoperatively. In 34 cases, arteriography was performed by direct puncture of the bypass below the proximal anastomosis. In the remaining 10 cases, flowmetry was performed (Transonic System HT 107). All patients stayed at least 24 hours in the intensive care unit. During the first year of follow-up, duplex scanning was performed every 3 months. Thereafter, continuous Doppler examination was performed at the same interval. If impaired patency of the PDB was suspected, duplex scanning was performed. Immediate and late patency as well as limb salvage rate were calculated using the actuarial method in conformity with the guidelines proposed by the Ad Hoc Committee on Reporting Standards in 1986.1
RESULTS No patient died during the procedure or the immediate postoperative period. The mean duration of hospitalization was 29 days. Postoperative complications included myocardial infarction in one case, crescendo angina in three cases treated successfully with nitrates, and pulmonary edema in one case. Early occlusion of the PDB occurred in three cases: two on the 1st postoperative day and one on the 3rd postoperative day. Surgical thrombectomy was attempted in two of these patients and failed and below-knee amputation was required in all three
Vol. 11, No. 5, 1997
Fig. 1. Primary patency curve calculated using the acturarial method. The number of bypasses at risk at the beginning of each interval is indicated above the horizontal axis.
cases. These patients presented diffuse, distal arterial disease associated with end-stage renal disease in two cases and thromboangeitis obliterans in one case. In the remaining 33 patients in whom 41 PDB were patent, complete healing of skin lesions was obtained by the time of discharge. Mean transcutaneous oxygen tension measured on the forefoot 21 days after the procedure was 60 ± 9 mmHg (versus 18 ± 7 mmHg preoperatively). In addition to revascularization, 46 surgical procedures were performed during the same period of hospitalization. These procedures were preoperative drainage of purulent collections in nine cases, amputation of one or more toes in 28 cases, transmetatarsal amputation in seven cases, re-operation of the surgical wound in one case, placement of a pedunculated skin flap on the heel in one case, and placement of a free flap using the latissimus dorsi muscle on the forefoot in one case. The mean duration of follow-up was 27 months (range 1 to 65 months). Late occlusion occurred at 5, 11, 17, 32, 35, and 41 months in six of the 33 patients with the 41 patent PDB. Amputation was required in four of these patients. In two cases, graft occlusion led not to recurrence of critical ischemia. Occlusion was never due to development of stenosis in the SFA or popliteal artery. In three cases, repeat surgery was required at 4, 7, and 41 months to re-establish or maintain patency of the PDB. In one of these cases, external compression of a sequential bypass led to thrombosis with subacute ischemia that was successfully treated by fibrinolysis. In the other two cases requiring reoperation, Doppler examination demonstrated hemodynamic changes but there were no symptomatic manifestations. In both cases, the PDB was prolonged distally
Popliteal-to-distal bypass grafts for limb salvage 507
Fig. 2. Secondary patency curve calculated using the actuarial method. The number of bypasses at risk at the beginning of each interval is indicated above the horizontal axis.
Fig. 3. Limb salvage curve calculated using the actuarial method. The number of limbs at risk at the beginning of each interval is indicated above the horizontal axis.
because of anastomatic stenosis of the anastomosis in one case and deterioration of runoff in the other. Development of new stenosis in the SFA or popliteal artery was never observed during follow-up. Occlusion of the PDB was not observed in any of the patients who presented preoperative lesions of the SFA (treated or not) and all preexisting lesions remained stable. Amputation was not required in any patient with a patent PDB. Primary graft patency (Fig. 1) was 83% at 1 year, 70.8% at 3 years, and 61.3% at 5 years. Secondary patency (Fig. 2) was 87.3% at 1 year, 74.0% at 3 years, and 69.0% at 5 years and the corresponding limb salvage rates (Fig. 3) were 90.0%, 82.0%, and 77.4%, respectively. There were four deaths during follow-up due to heart disease in three cases and cancer in one case. Of the four patients who were on chronic di-
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alysis, two died of myocardial infarction and one required major amputation.
DISCUSSION Until now, PDB has been shunned due to the putative medium- and long-term risk of loss or impairment of graft patency related to development of lesions in the SFA.2,3 However, this theoretical risk has not been borne out in practice. Wengerter et al.4 reported a series of 153 PDB in which late patency was 60% at 5 years. This rate is comparable with that achieved with bypasses originating from the common femoral artery. Medium-term patency was not significantly lower when PDB was performed downstream from SFA presenting untreated stenosis less than 35% or stenosis greater than 35% after successful preoperative balloon angioplasty. In contrast, untreated stenosis greater than 35% was associated with lower 2-year patency although this difference was not statistically significant. Our experience, albeit limited, confirms these findings. In the three patients presenting stenosis involving less than 30% of the lumen of the SFA, no progression was noted in the narrowing and the PDB were patent after 30, 39, and 42 months. The two lesions treated by balloon angioplasty showed no sign of restenosis. Development of new lesions in the SFA or popliteal artery was not detected during follow-up in any patient including those in whom thrombosis of the PDB occurred. None of the three re-interventions required to maintain graft patency involved the proximal arterial tree. Based on these observations it appears reasonable to assume that proximal anastomosis on the SFA or popliteal artery is safe provided that any reduction in the lumen of the artery is less than 30%. In cases of stenosis greater than 30%, careful evaluation is necessary to determine the indication for balloon angioplasty, which can be highly effective.5,6 Short, concentric lesions with no calcification can be confidently treated by balloon angioplasty, thus extending the indications for PDB. As described elsewhere,4,7-9 PDB is simple and quick to perform and less invasive for the patient. These advantages probably account for the low mortality rates reported in previous series: 0% by Rosenbloom et al.,8 0.8% by Stonebridge et al.,7 and 3.9% by Wengerter et al.4 In the present study there were no perioperative deaths. However, it should be noted that the mean age in our series was 62 years due to the high proportion of young diabetics. In this regard it should also be underlined that diabetic arterial disease often involves distal arteries without major upstream occlusion.10
Annals of Vascular Surgery
Another advantage of PDB is that it requires a short graft segment so that revascularization is feasible even in patients with limited vein graft availability. In two patients in the present series PDB was performed using the LSV because GVS was unavailable. In patients with full vein graft availability the surgeon can choose the most suitable piece of vein in terms of quality and size. Given the importance of graft quality in determining patency,11,12 this freedom of choice could be a major factor in the excellent outcome of PDB. In our series, graft quality was always optimal and thrombosis due to vein graft defects was not observed. Use of PDB also economizes substitute material for subsequent reconstruction if necessary. In most cases (86% in the present series), the GVS is placed in the reversed position because of the similar diameter of its malleolar and popliteal segments. This configuration avoids uncommon but well-documented complications of the in situ bypass technique related to valvulotomy and persistent arteriovenous fistula.13,14 Use of PDP also limits the number of skin incisions and avoids dissection of the inguinal region, which is a frequent cause of wound complications. In our series, localized, superficial disunion of the surgical incision occurred in only one case. This is in sharp contrast with the high incidence of wound complications varying from 17% to 44%, reported in series using the conventional in situ bypass technique.15-17 Because of their short length, PDB have better hemodynamics than longer grafts. In a retrospective study published in 1988, Ascer et al.18 showed that patency of short bypass was better than that of long bypasses especially when the outflow tract was poor. The fact that PDB originating from the infragenicular popliteal artery are not submitted to joint movement could also be an advantage. Infected tissue necrosis was present in 71% of the limbs revascularized in this series. Like other authors19,20 we attempted to promote healing by re-establishing flow to an artery in direct connection with the skin lesions. For the same reason we also performed sequential bypass whenever possible in these patients. Using this direct revascularization approach, prompt spontaneous healing of lesions was obtained in all cases. The fact that rapid healing was also achieved in the eight cases in which sequential bypass was performed supports the use of this aggressive approach. Secondary patency in our series was at 74% at 3 years and 69% at 5 years. Although follow-up is limited, these rates compare favorably with those obtained using conventional methods.21 Limb salvage rates were 82% at 3 years and 77% at 5 years.
Vol. 11, No. 5, 1997
Given the severity of the preoperative lesions these results are encouraging and justify continued use of this aggressive approach. Based on our experience, PDB appears to have numerous advantages that justify its routine use for limb salvage in patients without significant stenosis of the femoropopliteal axis.
Popliteal-to-distal bypass grafts for limb salvage 509
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