Refer to: Sproul G: Femoral tibial bypass grafts-The alternative to amputation. West J Med 128:291-293, Apr 1978
Femoral Tibial Bypass Grafts The Alternative to Amputation GORDON SPROUL, MD, San Diego
Severe ischemia and distal gangrene of lower extremities due to obstruction of the popliteal artery and its branches need not require major amputation. Autogenous vein grafts to the distal anterior tibial, posterior tibial, peroneal and dorsalis pedis arteries can avoid tissue loss in many instances. ONE HUNDRED femoral tibial grafts were carried out for threatened limb loss due to gangrene, rest pain and severe ischemia. A total of 85 grafts were initially successful. Lack of collateral connections to the arterial arcades of the foot appeared to influence patency adversely. No other criteria, such as vessel calcification, diabetes or local extent of disease, seemed critical. During the first year, an additional 11 grafts failed. Late failures occurred in four other grafts at 14, 19, 35, and 54 months, respectively. The 68 remaining grafts maintained patency until the patient's death or during follow-up of up to seven years. Major amputations were required in only 19 instances. Limb salvage achieved by this method of treatment suggests its use in limbs presently relegated to primary amputation.
Methods In 100 severely ischemic or gangrenous limbs, revascularization was carried out using reversed saphenous, cephalic or antecubital veins. All grafts originated at the common femoral or the upper portion of the superficial femoral artery, and terminated in the lower third of the leg or foot. Dr. Sproul is in private practice in San Diego. Submitted, revised, October 25, 1977. Reprint requests to: Gordon Sproul, MD, San Diego Cardiovascular Surgical Associates Medical Group, Inc., 3945 First Avenue, San Diego, CA 92103.
Most of the grafts were to the anterior tibial or dorsalis pedis arteries, but the peroneal and posterior tibial arteries were also used (Table 1). The vessel selected to receive the graft was that which had the most direct communications to the pedal arches (Figure 1). Calcification of the vessels did not preclude a successful procedure. Diabetes, which was present in 60 percent of the patients, did not appear to affect the outcome. Many of these patients were quite elderly; a majority being over 70 years of age (Table 2). Several technical aspects of the procedure seem important to assure success: * The use of fine monofilament continuous suture avoids damage to both the vein graft and the small diseased artery. * Passage of the grafts subcutaneously avoids the trauma inherent in such techniques as removal of a portion of the fibula, or passage through the interosseous membrane. Subcutaneous position assures the avoidance of kinking, and allows easy palpation to determine patency. * Inflation of the graft with heparinized saline after proximal anastomosis allows passage to the foot or lower leg without rotation. * Arteriograms after reconstruction may show undetected technical problems and allow immediate correction. THE WESTERN JOURNAL OF MEDICINE
291
FEMORAL TIBIAL BYPASS GRAFTS
No postoperative anticoagulants need be used and ambulation is begun immediately. *
Results Despite the advanced age and diabetic and arteriosclerotic state of these patients, the operations resulted in only three postoperative deaths. The late mortality was appreciable, with 32 patients succumbing to the complications of arteriosclerotic cardiovascular disease and carcinoma; TABLE 1.-Graft Site in 100 Femoral Tibial Grafts Anterior tibial ..... .... Posterior tibial ..... .... Dorsalis pedis ..... .... Peroneal ... ......
40 25 20 15
but 15 had open grafts and salvaged limbs. In all, 85 limbs were successfully grafted; two patients died of myocardial infarction in the postoperative period with patent grafts. There were 11 additional graft failures in the first year, and 4 late failures. In all the 15 operative failures, amputation was necessary and in 4 of the later failures, amputation likewise was required-a total of 19 limbs lost. Sixty-eight grafts remained patent until the patient's death or during a followup of up to seven years (Table 3). Long-term patency is limited by poor patient survival from advancing age and severe cardiovascular disease. Very few of these elderly patients, who present with severe ischemia or gangrene as a manifestation of their arteriosclerosis, will survive five years. With femoral tibial bypass grafting, it would appear that seven of ten such patients will live out their lives with their limbs intact. Grafts failed early due to technical problems involving the distal anastomosis or poor "runoff." Late failures were often the result of rather diffuse fibrotic hypertrophy of the vein wall. Occasionally, however, the fibrotic thickening of the vein wall was limited to a single location allowing simple patch repair and continued patency. Graft patency is unequivocally shown by palpation, as the grafts lie in the subcutaneum and are easily felt, particularly in the lower leg.
Discussion Figure 1.-An ideal candidate for posterior tibial bypass graft. TABLE 2.-Age Distribution of Patients Age
41-50 .. 51-60 61-70 .. 23 71-80 .. 35 81-90 .. 91-100 ...
Patients ...
3 12
16 1
TABLE 3.-Duration of Follow-up in Cases of Successful Revascularization 30 days--1 yr................. 1-2 years ..................... 2-3 years ..................... 3-4 years ..................... 4-5 years ..................... 5-6 years ..................... 6-7 years .....................
21 13 12 10 6 2 4 68
292
APRIL 1978 * 128 * 4
Stimulated by the report of Garrett' in 1966, we began to use the distal bypass for severely diseased extremities that would otherwise be subjected to amputation. We have been well satisfied with limb salvage and respectable patency rates, and find that this is now our most frequent operation in the leg below the groin. Our long-term results are quite similar to those of Tyson,2'3 and we agree with him that it appears the preferred operation over bypass to the isolated popliteal segment. The latter may not salvage the limb due to obstruction distal to the anastomosis, and uses one source of vein graft if it is not effective. We feel that the subcutaneous position of the graft is a definite advantage. It avoids bone removal or blind tunneling through the interosseous membrane; the former traumatizing a marginal limb unnecessarily and the latter lending itself to hemorrhage or graft kinking. Perhaps such techniques account for the lower patency rate noted by Imparato.4
FEMORAL TIBIAL BYPASS GRAFTS
The subcutaneous route has the additional late advantage of allowing auscultation and palpation of the graft in its entirety. One may easily then detect early reduction of pulses or bruits, indicating progressive graft stenosis from hypertrophy of the vein wall. The lesion can then be shown arteriographically, and simple repair can often be done under local anesthesia. Meticulous technique and attention to the details outlined will allow successful vein grafting to 1.5 to 2 mm distal vessels. Though increments of additional flow may not be large, they are directed to the most distal portions of the compromised limb (Figure 2). Pain at rest disappears
immediately following successful operation, and pregangrenous digits recover rapidly (Figure 3). Local debridement and minor amputation may then be done as necessary (Figure 4). Though early graft failure required amputation, some of the later failures maintained the healing promoted by the graft during its patency. When measured against a 20-percent to 30-percent operative mortality from major amputation, and the well recognized poor rehabilitation record of such patients, this procedure seems well worthwhile. When presented with a problem of gangrene and severe ischemia secondary to severe obstructive disease in the popliteal vessels and below, one's options for therapy are limited. One either carries out an amputation below the knee or above the knee, or attempts reconstruction. We feel our success with femoral tibial bypass grafting indicates that reconstruction is the preferable procedure.
Conclusion Femoral tibial vein grafting carries a small risk, is frequently successful in avoiding amputation and results in a useful extremity for the duration of the patient's life.
Figure 2.-A dorsalis pedis bypass graft with good foot filling.
REFERENCES 1. Garrett HE, DeBakey ME: Distal posterior tibial artery bypass with autogenous vein graft: A report of three cases. Surgery 60:283-287, Aug 1966 2. Reichle FA, Shuman CR, Tyson RR: Femorotibial bypass in the diabetic patient for salvage of the ischemic lower extremity. Am J Surg 129:603-605, Jun 1975 3. Reichle FA, Tyson RR: Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities. Ann Surg 182:449-455, Oct 1975 4. Imparato AM, Kim GE, Madayag M, et al: The results of tibial artery reconstruction procedures. Surg Gynecol Obstet 138:33-38, Jan 1974
I -i
A.
F -. -. ..
4-
Figure 3.-Typical lesiions -responding to this type of graft (same patient).
I;
Figure 4.-Well-healed very minor local amputations after a peroneal bypass graft. THE WESTERN JOURNAL OF MEDICINE
293
Femoral Tibial Bypass Grafts The Alternative to Amputation GORDON SPROUL, MD, San Diego
Severe ischemia and distal gangrene of lower extremities due to obstruction of the popliteal artery and its branches need not require major amputation. Autogenous vein grafts to the distal anterior tibial, posterior tibial, peroneal and dorsalis pedis arteries can avoid tissue loss in many instances. ONE HUNDRED femoral tibial grafts were carried out for threatened limb loss due to gangrene, rest pain and severe ischemia. A total of 85 grafts were initially successful. Lack of collateral connections to the arterial arcades of the foot appeared to influence patency adversely. No other criteria, such as vessel calcification, diabetes or local extent of disease, seemed critical. During the first year, an additional 11 grafts failed. Late failures occurred in four other grafts at 14, 19, 35, and 54 months, respectively. The 68 remaining grafts maintained patency until the patient's death or during follow-up of up to seven years. Major amputations were required in only 19 instances. Limb salvage achieved by this method of treatment suggests its use in limbs presently relegated to primary amputation.
Methods In 100 severely ischemic or gangrenous limbs, revascularization was carried out using reversed saphenous, cephalic or antecubital veins. All grafts originated at the common femoral or the upper portion of the superficial femoral artery, and terminated in the lower third of the leg or foot. Dr. Sproul is in private practice in San Diego. Submitted, revised, October 25, 1977. Reprint requests to: Gordon Sproul, MD, San Diego Cardiovascular Surgical Associates Medical Group, Inc., 3945 First Avenue, San Diego, CA 92103.
Most of the grafts were to the anterior tibial or dorsalis pedis arteries, but the peroneal and posterior tibial arteries were also used (Table 1). The vessel selected to receive the graft was that which had the most direct communications to the pedal arches (Figure 1). Calcification of the vessels did not preclude a successful procedure. Diabetes, which was present in 60 percent of the patients, did not appear to affect the outcome. Many of these patients were quite elderly; a majority being over 70 years of age (Table 2). Several technical aspects of the procedure seem important to assure success: * The use of fine monofilament continuous suture avoids damage to both the vein graft and the small diseased artery. * Passage of the grafts subcutaneously avoids the trauma inherent in such techniques as removal of a portion of the fibula, or passage through the interosseous membrane. Subcutaneous position assures the avoidance of kinking, and allows easy palpation to determine patency. * Inflation of the graft with heparinized saline after proximal anastomosis allows passage to the foot or lower leg without rotation. * Arteriograms after reconstruction may show undetected technical problems and allow immediate correction. THE WESTERN JOURNAL OF MEDICINE
291
FEMORAL TIBIAL BYPASS GRAFTS
No postoperative anticoagulants need be used and ambulation is begun immediately. *
Results Despite the advanced age and diabetic and arteriosclerotic state of these patients, the operations resulted in only three postoperative deaths. The late mortality was appreciable, with 32 patients succumbing to the complications of arteriosclerotic cardiovascular disease and carcinoma; TABLE 1.-Graft Site in 100 Femoral Tibial Grafts Anterior tibial ..... .... Posterior tibial ..... .... Dorsalis pedis ..... .... Peroneal ... ......
40 25 20 15
but 15 had open grafts and salvaged limbs. In all, 85 limbs were successfully grafted; two patients died of myocardial infarction in the postoperative period with patent grafts. There were 11 additional graft failures in the first year, and 4 late failures. In all the 15 operative failures, amputation was necessary and in 4 of the later failures, amputation likewise was required-a total of 19 limbs lost. Sixty-eight grafts remained patent until the patient's death or during a followup of up to seven years (Table 3). Long-term patency is limited by poor patient survival from advancing age and severe cardiovascular disease. Very few of these elderly patients, who present with severe ischemia or gangrene as a manifestation of their arteriosclerosis, will survive five years. With femoral tibial bypass grafting, it would appear that seven of ten such patients will live out their lives with their limbs intact. Grafts failed early due to technical problems involving the distal anastomosis or poor "runoff." Late failures were often the result of rather diffuse fibrotic hypertrophy of the vein wall. Occasionally, however, the fibrotic thickening of the vein wall was limited to a single location allowing simple patch repair and continued patency. Graft patency is unequivocally shown by palpation, as the grafts lie in the subcutaneum and are easily felt, particularly in the lower leg.
Discussion Figure 1.-An ideal candidate for posterior tibial bypass graft. TABLE 2.-Age Distribution of Patients Age
41-50 .. 51-60 61-70 .. 23 71-80 .. 35 81-90 .. 91-100 ...
Patients ...
3 12
16 1
TABLE 3.-Duration of Follow-up in Cases of Successful Revascularization 30 days--1 yr................. 1-2 years ..................... 2-3 years ..................... 3-4 years ..................... 4-5 years ..................... 5-6 years ..................... 6-7 years .....................
21 13 12 10 6 2 4 68
292
APRIL 1978 * 128 * 4
Stimulated by the report of Garrett' in 1966, we began to use the distal bypass for severely diseased extremities that would otherwise be subjected to amputation. We have been well satisfied with limb salvage and respectable patency rates, and find that this is now our most frequent operation in the leg below the groin. Our long-term results are quite similar to those of Tyson,2'3 and we agree with him that it appears the preferred operation over bypass to the isolated popliteal segment. The latter may not salvage the limb due to obstruction distal to the anastomosis, and uses one source of vein graft if it is not effective. We feel that the subcutaneous position of the graft is a definite advantage. It avoids bone removal or blind tunneling through the interosseous membrane; the former traumatizing a marginal limb unnecessarily and the latter lending itself to hemorrhage or graft kinking. Perhaps such techniques account for the lower patency rate noted by Imparato.4
FEMORAL TIBIAL BYPASS GRAFTS
The subcutaneous route has the additional late advantage of allowing auscultation and palpation of the graft in its entirety. One may easily then detect early reduction of pulses or bruits, indicating progressive graft stenosis from hypertrophy of the vein wall. The lesion can then be shown arteriographically, and simple repair can often be done under local anesthesia. Meticulous technique and attention to the details outlined will allow successful vein grafting to 1.5 to 2 mm distal vessels. Though increments of additional flow may not be large, they are directed to the most distal portions of the compromised limb (Figure 2). Pain at rest disappears
immediately following successful operation, and pregangrenous digits recover rapidly (Figure 3). Local debridement and minor amputation may then be done as necessary (Figure 4). Though early graft failure required amputation, some of the later failures maintained the healing promoted by the graft during its patency. When measured against a 20-percent to 30-percent operative mortality from major amputation, and the well recognized poor rehabilitation record of such patients, this procedure seems well worthwhile. When presented with a problem of gangrene and severe ischemia secondary to severe obstructive disease in the popliteal vessels and below, one's options for therapy are limited. One either carries out an amputation below the knee or above the knee, or attempts reconstruction. We feel our success with femoral tibial bypass grafting indicates that reconstruction is the preferable procedure.
Conclusion Femoral tibial vein grafting carries a small risk, is frequently successful in avoiding amputation and results in a useful extremity for the duration of the patient's life.
Figure 2.-A dorsalis pedis bypass graft with good foot filling.
REFERENCES 1. Garrett HE, DeBakey ME: Distal posterior tibial artery bypass with autogenous vein graft: A report of three cases. Surgery 60:283-287, Aug 1966 2. Reichle FA, Shuman CR, Tyson RR: Femorotibial bypass in the diabetic patient for salvage of the ischemic lower extremity. Am J Surg 129:603-605, Jun 1975 3. Reichle FA, Tyson RR: Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities. Ann Surg 182:449-455, Oct 1975 4. Imparato AM, Kim GE, Madayag M, et al: The results of tibial artery reconstruction procedures. Surg Gynecol Obstet 138:33-38, Jan 1974
I -i
A.
F -. -. ..
4-
Figure 3.-Typical lesiions -responding to this type of graft (same patient).
I;
Figure 4.-Well-healed very minor local amputations after a peroneal bypass graft. THE WESTERN JOURNAL OF MEDICINE
293
