Preservation of the Ischemic Leg by Distal Vascular Bypass WILLIAM TURNIPSEED, M.D.,* WILLIAM EVANS, M.D.,t JOHN S. VASKO, M.D.t
From the Department of Surgery, University of Wisconsin Center for Health Sciences, Madison, Wisconsin and the Department of Surgery, Ohio State University Hospitals, Columbus, Ohio
Autogenous saphenous vein bypass grafts to tibial or peroneal
vessels have resulted in successful, long-term limb preservation in appropriately selected patients. This success appears to justify an aggressive approach to what has previously been considered "end-stage" distal vascular occlusive disease. This report describes the clinical management and long-term follow-up of 41 patients with tibial artery reconstruction.
maintain graft function particularly if the dorsal arterial arcades are patent and communicate (1).
FROM JULY, 1969, TO DECEMBER, 1974,43 saphenous vein grafts to the tibial or peroneal vessels were performed in 41 patients. There were 33 men and 8 women ranging in age from 19 to 80 years with a mean of 62 years. The majority (39) were within 10 pounds of ideal weight and most (29) were heavy smokers (1pk/day). Cardiac disease was prevalent in those above 50 years of age (infarct 28%, angina 10o, arrhythmia 10%o, failure 10%o) and diabetes mellitus was documented in 16 cases. Hypertension (> 160/90) was present in 12. Only five of 20 patients with aortic iliac occlusive disease had previous aortic femoral bypass. All patients selected for tibial artery bypass faced the eminent prospect of ischemic limb loss from one of the following causes: Atherosclerosis with rest pain and/or gangrene (33); traumatic distal ischemia (4); popliteal aneurysm with thrombosis (4). None of the operations were done for claudication alone (Fig. 1). Accurate distal lower extremity arteriograms are a prerequisite for tibial reconstruction. The best angiographic results are obtained from percutaneous femoral injections with delayed films to visualize distal vascular channels (1,10,11). Failure to identify patent vessels below the popliteal artery is not an absolute contraindication for tibial reconstruction. Surgical exploration is often necessary to determine the feasibility of small vessel bypass (5). A single tibial or peroneal vessel patent distally can provide adequate "runoff' to Submitted for publication June 29, 1976. *University of Wisconsin Center for Health Sciences Department of Surgery, Madison, Wisconsin. tOhio State University Hospitals Department of Surgery, Columbus, Ohio. Correspondence to: William Turnipseed, M.D., Veterans Administration Hospital, Department of Surgery, 2500 Overlook Terrace, Madison, Wisconsin 53706.
659
Methods
All surgery is performed using general anesthesia. Utilizing a team approach, the femoral artery and saphenous vein are exposed through a vertical groin incision while the distal vessel preselected by arteriography for bypass reconstruction is simultaneously isolated through an appropriate incision below the knee. Although the tibial-peroneal trunk is the preferred site for the lower anastomosis, severe occlusive disease or trauma in the area often makes a more distal arterial branch the appropriate point for saphenous bypass. Relative ease of exposure and direct communication with the vascular arcades in the foot make the posterior tibial artery the most common choice in these circumstances. The proposed site of anastomosis should be distal to all significant lesions. Meticulous handling of tissues and adequate exposure of the tibial vessel is mandatory. After the saphenous vein is prepared and the intramuscular graft channel dissected, the patient is given systemic heparin (1 mg/kg). A one to one-and-a-half centimeter longitudinal arteriotomy is then made. If adequate back flow from the distal artery is obtained, the vessel is enlarged with arterial dilators, and an end-to-side anastomosis performed employing a continuous suture technique with a 6-0 proline (Fig. 2). This anastomosis is tested for significant leaks by injecting heparinized saline under pressure through the graft into the distal vessel. The graft filled with heparinized saline is then passed retrograde through the intramuscular channel along the course of the host vessel with proper orientation to avoid twisting and brought out in the inguinal incision where an end-to-side anastomosis is routinely made to the common femoral artery. When appropriate, however, the superficial or pro-
TURNIPSEED, EVANS AND VASKO
660
Ann. Surg. * November 1977
FIG. 1. Indications for fem-
oral-tibial bypass.
fundus femoris may be used. Ten milligrams of paverine hydrochloride diluted in 10 cc of heparinized saline injected into the graft prior to reconstituting arterial flow appears to reduce arterial spasm and out-flow resistance that often occurs with operative manipulation. Subcutaneous fasciotomy is routinely performed through the operative incision before skin closure. Intra-operative arteriography is performed in all cases.
Despite 19 graft failures, only 9 amputations were necessary, all related to graft occlusion within 6 months of surgery. Grafts patent for more than two years had a subsequent failure rate of less than 10%o (Table 1). Five of 41 patients in the study expired. All deaths were due to stroke or myocardial infarction and occurred within the first year after surgery. None of those who died had an amputation.
Results
Discussion It should be emphasized that bypass grafting to the tibial and peroneal arteries had been reserved for those patients with "end-stage" or acute, limb-threatening ischemia who, without vascular reconstruction, would ultimately require amputation.1'2'6'8'11 Indications for operation include trauma with destruction of the. popliteal artery and proximal portions of its branches, and severe ischemia resulting from atherosclerotic involvement of these vessels with rest pain, ischemia, ulceration, or gangrene. The importance of adequate lower extremity arteriograms cannot be overemphasized in this group of patients.4'9 It is critical that visualization of the arterial system be obtained from groin to toes because distal vessels are frequently patent when popliteal and proximal tibial-peroneal injury or obstruction occurs.5 The surgeon must also be assured that there are no proximal aorto-iliac and/or femoral-profunda lesions which may compromise arterial inflow and jeopardize otherwise successful bypass to lower leg vessels. Adequate exposure, meticulous technique, and
Preoperative arteriography demonstrated severe occlusive disease or arterial trauma to the proximal tibial vessels in 23 patients. Single vessel patency at the ankle was demonstrated in 28, double vessel patency in 8 and triple vessel patency in only five. In the 43 ischemic extremities 28 posterior tibial, ten anterior tibial, and five peroneal bypass grafts were performed for limb salvage. A reversed autogenous saphenous vein was used in 38 of 43 arterial bypass reconstructions and composite grafts (dacronsaphenous) were used in five. Ipsilateral lumbar sympathectomy was performed with the bypass in 19 cases where distal vessels were patent but diffusely diseased and the likelihood of graft failure was higher. Immediate graft patency was confirmed in 39 of 43 grafts by using intraoperative arteriography. Four grafts failed outright and five thrombosed in the early postoperative period. All extremities in which the bypass attempt failed at surgery ultimately required amputation. Prompt surgical reexploration successfully restored patency and assured limb salvage in four of five patients with early postoperative graft occlusion.
placement of the lower anastomosis distal to all sig-
Vol. 186oNo. 5
ISCHEMIC LEG PRESERVATION
nificant stenotic lesions are prerequisites for good surgical results. Easy access to the terminal branches of the popliteal artery. is made through a medial incision made just below the knee where the posterior muscle group attaches to the tibia. Distal exposure of the posterior tibial artery can be made through an incision placed posterior and cephalad to the medial maleolus when obstruction or severe tissue trauma makes a more proximal incision unfeasible. Exposure of the anterior tibial artery is made through an anterolateral incision and the graft tunneled through the interosseous membrane so as to follow the anatomic course of the host vessel. The saphenous graft is usually harvested from the ischemic limb using groin and distal medial skin incisions in the thigh and calf. Inadequate size (
From the Department of Surgery, University of Wisconsin Center for Health Sciences, Madison, Wisconsin and the Department of Surgery, Ohio State University Hospitals, Columbus, Ohio
Autogenous saphenous vein bypass grafts to tibial or peroneal
vessels have resulted in successful, long-term limb preservation in appropriately selected patients. This success appears to justify an aggressive approach to what has previously been considered "end-stage" distal vascular occlusive disease. This report describes the clinical management and long-term follow-up of 41 patients with tibial artery reconstruction.
maintain graft function particularly if the dorsal arterial arcades are patent and communicate (1).
FROM JULY, 1969, TO DECEMBER, 1974,43 saphenous vein grafts to the tibial or peroneal vessels were performed in 41 patients. There were 33 men and 8 women ranging in age from 19 to 80 years with a mean of 62 years. The majority (39) were within 10 pounds of ideal weight and most (29) were heavy smokers (1pk/day). Cardiac disease was prevalent in those above 50 years of age (infarct 28%, angina 10o, arrhythmia 10%o, failure 10%o) and diabetes mellitus was documented in 16 cases. Hypertension (> 160/90) was present in 12. Only five of 20 patients with aortic iliac occlusive disease had previous aortic femoral bypass. All patients selected for tibial artery bypass faced the eminent prospect of ischemic limb loss from one of the following causes: Atherosclerosis with rest pain and/or gangrene (33); traumatic distal ischemia (4); popliteal aneurysm with thrombosis (4). None of the operations were done for claudication alone (Fig. 1). Accurate distal lower extremity arteriograms are a prerequisite for tibial reconstruction. The best angiographic results are obtained from percutaneous femoral injections with delayed films to visualize distal vascular channels (1,10,11). Failure to identify patent vessels below the popliteal artery is not an absolute contraindication for tibial reconstruction. Surgical exploration is often necessary to determine the feasibility of small vessel bypass (5). A single tibial or peroneal vessel patent distally can provide adequate "runoff' to Submitted for publication June 29, 1976. *University of Wisconsin Center for Health Sciences Department of Surgery, Madison, Wisconsin. tOhio State University Hospitals Department of Surgery, Columbus, Ohio. Correspondence to: William Turnipseed, M.D., Veterans Administration Hospital, Department of Surgery, 2500 Overlook Terrace, Madison, Wisconsin 53706.
659
Methods
All surgery is performed using general anesthesia. Utilizing a team approach, the femoral artery and saphenous vein are exposed through a vertical groin incision while the distal vessel preselected by arteriography for bypass reconstruction is simultaneously isolated through an appropriate incision below the knee. Although the tibial-peroneal trunk is the preferred site for the lower anastomosis, severe occlusive disease or trauma in the area often makes a more distal arterial branch the appropriate point for saphenous bypass. Relative ease of exposure and direct communication with the vascular arcades in the foot make the posterior tibial artery the most common choice in these circumstances. The proposed site of anastomosis should be distal to all significant lesions. Meticulous handling of tissues and adequate exposure of the tibial vessel is mandatory. After the saphenous vein is prepared and the intramuscular graft channel dissected, the patient is given systemic heparin (1 mg/kg). A one to one-and-a-half centimeter longitudinal arteriotomy is then made. If adequate back flow from the distal artery is obtained, the vessel is enlarged with arterial dilators, and an end-to-side anastomosis performed employing a continuous suture technique with a 6-0 proline (Fig. 2). This anastomosis is tested for significant leaks by injecting heparinized saline under pressure through the graft into the distal vessel. The graft filled with heparinized saline is then passed retrograde through the intramuscular channel along the course of the host vessel with proper orientation to avoid twisting and brought out in the inguinal incision where an end-to-side anastomosis is routinely made to the common femoral artery. When appropriate, however, the superficial or pro-
TURNIPSEED, EVANS AND VASKO
660
Ann. Surg. * November 1977
FIG. 1. Indications for fem-
oral-tibial bypass.
fundus femoris may be used. Ten milligrams of paverine hydrochloride diluted in 10 cc of heparinized saline injected into the graft prior to reconstituting arterial flow appears to reduce arterial spasm and out-flow resistance that often occurs with operative manipulation. Subcutaneous fasciotomy is routinely performed through the operative incision before skin closure. Intra-operative arteriography is performed in all cases.
Despite 19 graft failures, only 9 amputations were necessary, all related to graft occlusion within 6 months of surgery. Grafts patent for more than two years had a subsequent failure rate of less than 10%o (Table 1). Five of 41 patients in the study expired. All deaths were due to stroke or myocardial infarction and occurred within the first year after surgery. None of those who died had an amputation.
Results
Discussion It should be emphasized that bypass grafting to the tibial and peroneal arteries had been reserved for those patients with "end-stage" or acute, limb-threatening ischemia who, without vascular reconstruction, would ultimately require amputation.1'2'6'8'11 Indications for operation include trauma with destruction of the. popliteal artery and proximal portions of its branches, and severe ischemia resulting from atherosclerotic involvement of these vessels with rest pain, ischemia, ulceration, or gangrene. The importance of adequate lower extremity arteriograms cannot be overemphasized in this group of patients.4'9 It is critical that visualization of the arterial system be obtained from groin to toes because distal vessels are frequently patent when popliteal and proximal tibial-peroneal injury or obstruction occurs.5 The surgeon must also be assured that there are no proximal aorto-iliac and/or femoral-profunda lesions which may compromise arterial inflow and jeopardize otherwise successful bypass to lower leg vessels. Adequate exposure, meticulous technique, and
Preoperative arteriography demonstrated severe occlusive disease or arterial trauma to the proximal tibial vessels in 23 patients. Single vessel patency at the ankle was demonstrated in 28, double vessel patency in 8 and triple vessel patency in only five. In the 43 ischemic extremities 28 posterior tibial, ten anterior tibial, and five peroneal bypass grafts were performed for limb salvage. A reversed autogenous saphenous vein was used in 38 of 43 arterial bypass reconstructions and composite grafts (dacronsaphenous) were used in five. Ipsilateral lumbar sympathectomy was performed with the bypass in 19 cases where distal vessels were patent but diffusely diseased and the likelihood of graft failure was higher. Immediate graft patency was confirmed in 39 of 43 grafts by using intraoperative arteriography. Four grafts failed outright and five thrombosed in the early postoperative period. All extremities in which the bypass attempt failed at surgery ultimately required amputation. Prompt surgical reexploration successfully restored patency and assured limb salvage in four of five patients with early postoperative graft occlusion.
placement of the lower anastomosis distal to all sig-
Vol. 186oNo. 5
ISCHEMIC LEG PRESERVATION
nificant stenotic lesions are prerequisites for good surgical results. Easy access to the terminal branches of the popliteal artery. is made through a medial incision made just below the knee where the posterior muscle group attaches to the tibia. Distal exposure of the posterior tibial artery can be made through an incision placed posterior and cephalad to the medial maleolus when obstruction or severe tissue trauma makes a more proximal incision unfeasible. Exposure of the anterior tibial artery is made through an anterolateral incision and the graft tunneled through the interosseous membrane so as to follow the anatomic course of the host vessel. The saphenous graft is usually harvested from the ischemic limb using groin and distal medial skin incisions in the thigh and calf. Inadequate size (
