Br. J. Surg. Vol. 63 (1976) 371-376

Salvage of the lower limb Y . N. Y O G A S U N D R A M * SUMMARY

This is a retrospective study OJ 80 patients with 94 severely ischaemic lower limbs treated over a period of' 6 years. Arterial reconstruction was possible in 47 patients (54 limbs) and 76 per cent of' these limbs were salvaged. There was no operative mortality. An attempt has been made to analyse the reasons for the failure. The fate of the patients who underwent major amputation i s described. The selection of patients for direct arterial surgery is discussed, together with some o f the technical problems involved. THEelderly patient with severe chronic ischaemia of one or both lower limbs, due to atherosclerosis, presents an increasingly common problem in most general surgical units. The number of major amputations carried out because of degenerative arterial disease is increasing year by year, and these elderly amputees make heavy demands on the social and welfare services (Harris et al., 1974). There have been several encouraging reports on the results of limb salvage operations over the past few years. Taylor (1971) reported salvage rates of 83 and 80 per cent at 1 year for aorto-iliac and femoropopliteal reconstructions respectively. Baddeley et al. (1970) had a salvage rate of 74.4 per cent with autogenous bypass vein grafts for femoropopliteal occlusions. Minken et al. (1968) found a 78 per cent patency rate when aorto-iliac reconstruction was carried out for rest pain, ischaemic ulceration or gangrene in 77 patients. It would seem, however, that many general surgeons are still reluctant to embark on what could be a fruitless and time-consuming surgical adventure on an elderly patient. Some patients are mistakenly denied the opportunity of remaining ambulant on comfortable and viable limbs. The present study was instituted to determine the outcome of the treatment undertaken in patients with severely ischaemic lower limbs over a 6-year period at a small peripheral hospital. The main aims of this paper are to present an overall picture of the results of treatment, to confirm that a considerable number of limbs can be salvaged with negligible operative mortality and morbidity and to discuss the selection of patients for direct arterial surgery. The term 'severe ischaemia' is used here to mean ischaemia severe enough to warrant major amputation unless the limb can be salvaged by direct arterial surgery. Patients and methods From January 1969 to December 1974, 80 patients with 94 severely ischaemic lower limbs were treated.

In every case the pathological diagnosis was atherosclerosis. Every patient has been traced and those who underwent direct arterial surgery have been seen in the follow-up clinic at regular intervals. The maximum period of follow-up is 6 years 4 months, and the minimum 6 months. All the patients presented with persistent and severe pain at rest. Ischaemic ulceration, frank gangrene or both were present in 77 limbs. Age and sex incidence

The age range was from 46 to 92 years. The age distribution is shown in Fig. I . There were 62 males and 18 females.

'"1

16

40-49 50-59 Age in decades

60-69

16

70-79

80-89

90+

Direct arterial surgery Major amputat'ion without direct arterial surgery

Fig. 1 . Age distribution of 80 patients with severe ischaemia of the lower limbs.

Initial assessment The initial consideration was whether the patient could make use of the limb if it was salvaged. Limbs that were paralysed, grossly arthritic, deformed by fixed flexion contractures or already involved by extensive gangrene underwent immediate major amputation. The rest were considered for direct arterial surgery, and femoral arteriography or aortography was carried out. The exceptions were a few limbs in which a popliteal pulse was palpable, and these patients underwent below-knee amputation.

* Chorley and

District Hospital, Chorley, Lancs.

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Y. N. Yogasundram Aorto-iliac endarterectomy was carried out in 8 cases using a combination of the ‘open’ and ‘closed’ methods, endarterectomy loops being used for the 16 Immediate major amputation without arteriolatter. The common femoral and profunda arteries graphy (limb not worth salvaging) Below-knee amputation without arteriography 3 were first explored and patency established before (popliteal pulse palpable) the abdomen was opened. In 2 of the 8 limbs the Aortography or femoral arteriography 75 origin of the profunda femoris was widened using a ‘boomerang’ vein patch (Martin et al., 1968). Lumbar Table 11: ASSOCIATED DISORDERS sympathectomy was also carried out in 5 cases. Patients (47) A Dacron prosthesis was used for a bypass from undergoing Patients (33) the aorta to the common femoral artery in one patient arterial undergoing who had previously undergone surgery on the iliac Disorder surgery amputation vessels. lschaemic heart disease 28 16 Profundaplasty, consisting of endarterectomy of 5 8 Hypertension Previous cerebrovascular accident 2 8 the common femoral carried down into the profunda 16 21 Atherosclerotic occlusion in the for about 4cm, the arteriotomy being closed by a contralateral limb vein patch, was carried out as the sole procedure in 9 13 Chronic lung disease one patient who had extensive femoropopliteal occh4 5 Diabetes 0 2 Malignant disease sion (unsuitable for bypass grafting) and narrowing of the profunda origin. The long saphenous vein was used for one of the Table 111: TYPES OF DIRECT ARTERIAL SURGERY PERFORMED crossover femorofemoral grafts and an 8-mm Dacron prosthesis for the other. Both these patients were unNo. of limbs Operation suitable for major abdominal surgery. The grafts were Aorto-iliac endarterectomy 8* tunnelled through the superficial fascia of the supraAortofemoral bypass (Dacron) graft 1 Fernorofernoral cross-over graft 2 pubic region. Profundaplasty 1 Reversed autogenous long saphenous veins were Femoropopliteal bypass vein graft 40t inserted for the femoropopliteal and femorotibial Femorotibial passby vein graft 2 grafts. The upper and lower levels of anastomosis * Bilateral in one patient. were decided upon after inspection and palpation of t Bilateral in 6 patients. the vessels at operation. The two femorotibial grafts were done on limbs in which the popliteal arteries Table 1V: PATENCY OF DISTAL VESSELS IN LIMBS were found to be unsuitable for anastomosis at operaWHICH UNDERWENT BYPASS GRAFTING FOR FEMOROPOPLITEAL OCCLUSION tion, although shown to be patent on arteriography. Where exposure of the distal popliteal was required, No. of No. of % of total failures Patency limbs the medial head of the gastrocnemius was divided. The soleus was scraped off its insertion for exposure 9 21.4 3 Two tibial vessels patent One tibial vessel patent 19 45.2 5 of the posterior tibial trunk. Tibia1 and peroneal vessels 14 33.4 4 Heparin (5000 units) was injected intravenously occluded during the operation. Anticoagulants were not routinely administered postoperatively. The outcome of the initial asscssrnent is shown in Patency ofdistal vessels: All 11 limbs with occlusions Table I. of the aorto-iliac segments also had femoropopliteal Of the 75 limbs investigated by aortography or occlusions. femoral arteriography, 54 (72 per cent) were selected A poor outflow was encountered in a considerable for some form of arterial reconstruction. The rest number of the limbs with occlusions of the femoro(21 limbs) were amputated. popliteal segments (Table W ) . Levels ofanastomosis andgraft diameter : The proximal Associated disorders anastomosis was to the common femoral in 30 limbs Evidence of vascular involvement elsewhere was, as and to the superficial femoral in 12. The distal anastoone would expect, a common finding. Of the 37 mosis was to the posterior tibial trunk in 2, the poplipatients with vascular involvement in the opposite teal below-knee-joint level in 21, at the level of the limb (Table II), 14 developed severe ischaemia in knee joint in 8 and above the level of the knee joint that limb during the 6-year period. Of these, 7 under- in 1 1 limbs. went direct arterial surgery and 7 were amputated. The diameter of the graft was less than 4 mm when distended in 5 cases. Direct arterial surgery Treatment of necrotic areas: Thirty-eight of the 54 The various forms of surgery carried o u t on the 54 limbs had areas of ischaemic ulceration, frank ganlimbs are set out in Table 111. Preoperative aorto- grene or both. Nineteen of these limbs required minor graphy was carried out by the translumbar route and amputations or excision of slough followed by splitfemoral arteriography by simple puncture of the skin grafting. These minor procedures were usually common femoral artery. carried out 2-3 weeks after the main operation. Table I: OUTCOME OF INITIAL ASSESSMENT No. of limbs Procedure

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Salvage of the lower limb Major amputations Forty limbs (42 per cent of the total) were amputated without any attempt at arterial surgery. Twelve of these limbs had an unsuccessful lumbar sympathectomy prior to amputation. There were 37 above-knee and 3 below-knee amputations. One below-knee and 12 above-knee amputations were carried out on patients in whom arterial surgery had failed. Thus, altogether there were 53 major amputations on 45 patients. Equal anteroposterior flaps containing full-thickness muscle were raised for the above-knee amputations and a myoplastic procedure with a long posterior flap was used for the below-knee amputations (HunterCraig et al., 1970).

Results of direct arterial surgery Mortality There was no operative mortality. Thirteen of the 34 patients who underwent successful direct arterial surgery have died during the follow-up period, an overall mortality of 38.2 per cent. The causes of death were myocardial infarction (6), cerebrovascular accident (2), mesenteric thrombosis (l), pulmonary embolus (I), congestive cardiac failure (I), carcinoma of the lung (1) and carcinoma of the stomach (1). Morbidity Table V lists the postoperative complications. The superficial wound infections resolved rapidly. The 4 patients with haematoma developed small areas of necrosis along the suture line which took up to 6 weeks to heal. Primary haemorrhage from a tributary of the long saphenous vein necessitated a second operation on the same day. The bleeding was easily controlled. Postoperative oedema of the foot and ankle has been attributed to venous thrombosis (Ernst et al., 1964), to increased capillary filtration (Husni, 1967) and to interruption of lymphatics (Vaughan et al., 1970). In this series mild to moderate oedema occurred in 23 of the 42 limbs in which vein grafts were used for femoropopliteal occlusions. However, it was persistent in only 2 patients. Hyperaesthesia of the medial aspect of the knee disappeared spontaneously in 2 of the 3 patients within a few months. It has persisted in one patient. Two of the 4 patients with pressure necrosis of the heel underwent amputation because of early graft failure, and in the other 2 the ulcers ultimately healed. One of the patients who developed acute retention later underwent prostatectomy. Both patients who developed paralytic ileus after aorto-iliac surgery responded satisfactorily to the usual conservative measures. Salvage rate Forty-one out of the 54 limbs (76 per cent) were successfully salvaged (Table VZ). Aorto-iliac occlusion: All 1 1 limbs with occlusions of the aorto-iliac segments were salvaged (Table VZ). The duration of follow-up is shown in Table VZZ. Fernoropopliteal occlusion : The profundaplasty that was carried out on a patient with an extensive femoro-

Table V: POSTOPERATIVE COMPLICATIONS Complication

No. of patients

Superficial wound infection Wound haematoma Primary haemorrhage Oedema of foot and ankle Hyperaesthesia, medial aspect of knee Heel ulceration Retention of urine Paralytic ileus

2 4 1 23 3 4 3 2

Table VI: SALVAGE RATES

No. of No. % Operation operations salvaged salvaged Aorto-iliac endarterectomy X X 100 Aortofemoral bypass 1 1 I 00 Cross-over femorofemoral 2 2 100 bypass Profundaplasty 1 0 0 Femoropopliteal and femoro42 30 71 tibia1 bypass Total

54

41

16

Table VII: DURATION OF FOLLOW-UP IN PATIENTS WITH AORTO-ILIAC OCCLUSION Duration No. of limbs No. of uatients No. of deaths 6 mth-1 yr 3 3 0 1-2 yr 3 2* 0 2 2 2-3 yr 2 2t I 3-4 yr 2 4-5 yr 0 0 0 1 0 5-6 vr 1 Total 11 10 3

* One patient had a Dacron cross-over graft. t One patient had a cross-over vein graft. Table VIII: DURATION OF FOLLOW-UP IN PATIENTS WITH SUCCESSFUL GRAFTS Duration No. of limbs No. of patients No. of deaths 6 mth-1 yr 6' 4 0 1-2 yr 6 6 3 2-3 yr 4 2 0 3-4 yr 5' 4 2 4-5 yr 3 3 1 vr4 3 3 -5-6 ., 6-7 yr 2 2 1 Total 30 24 10

* Includes one femorotibial graft. Table IX: TIME BETWEEN ARTERIAL SURGERY AND AMPUTATION IN PATIENTS WITH FAILED BYPASS VEIN GRAFTS No. of limbs: Time: 0-1 mth 1-2 mth 2-3 mth 5-6 mth Total

5

2 3 2

12

popliteal occlusion and narrowing of the profunda origin was a failure and resulted in amputation 1 week later. The outcome of the bypass vein grafts is shown in Tables VfZZ and f X . All the failures in this series have occurred within 6 months of operation. In 2 cases,

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Y. N. Yogasundram although the grafts had obviously occluded, one at 6 months and the other at 8 months after the operation, neither patient complained of rest pain and necrotic areas had healed. Both patients claudicated at about 100 yards. The primary purpose of limb salvage had been achieved in these patients and they have been listed as successes. This ‘tiding-over’ concept has been well documented (Baddeley et al., 1970; Taylor, 1971; Horton, 1974). Seventy-one per cent of the limbs on which bypass vein grafting was carried out for femoropopliteal occlusions were salvaged. Analysis of failures When the failed vein grafts were examined more closely, neither the sites of anastomosis nor the radiological patency of the distal vessels appeared to be of significance. However, if the graft diameter is taken into account, 3 of the early failures occurred in limbs where a graft of less than 4 m m was used from the common femoral to the distal popliteal artery. One early failure was due to a poor ‘run-in’. This patient had an undiagnosed narrowing of the iliac vessels. The rest (6) of the failures which occurred during the first 3 months were very probably due to poor judgement in carrying out the distal anastomosis to a grossly sclerotic arterial wall. In 5 of these limbs, dissection after amputation revealed a relatively healthy segment of arterial wall distal to the site chosen for anastomosis. One of the failures which occurred between 5 and 6 months was due to progression of the disease in the distal vessels. This patient had recurrent rest pain and gangrene despite a palpable popliteal pulse and a patent graft on arteriography. It was possible to carry out a below-knee amputation. The reason for the other late failure is obscure. The graft was noted to be occluded when above-knee amputation was carried out. The profundaplasty carried out as the sole procedure probably failed because of extensive disease already present in the distal vessels. In retrospect this patient was not suitable for any form of arterial reconstruction.

bronchopneumonia which was controlled by physiotherapy and antibiotics. One patient had a pulmonary infarct and had to be anticoagulated. Three patients had postoperative retention of urine and 2 of these required prostatectomy. Ischaemic ulceration occurred on the heel of the contralateral limb in one patient and she later underwent above-knee amputation of that leg as well. Mobility Thirty-three of the 45 amputees were supplied with an artificial limb. Eight of these patients made fair use of their artificial limb, usually aided by a stick. The rest made very little use of the limb and were more or less confined to a wheelchair.

Discussion Palliative operations, as these undoubtedly are, should ideally have a low operative mortality and morbidity together with a high rate of palliation. In addition, they should preferably be simple and quick to perform. Operations on the peripheral vessels are comparatively minor procedures with regard to their general effect, and the majority of papers report a low mortality rate. The morbidity is also relatively minor. In this series the only two persistent complications have been mild to moderate oedema of the foot and ankle in 2 patients and hyperaesthesia on the medial aspect of the knee in one patient. Unfortunately, however, these operations are time-consuming and this is presumably one of the reasons for their lack of popularity amongst many general surgeons. In contrast, the operation of lumbar sympathectomy is simple and short. Edwards and Crane (1961), reporting on 100 patients over a 10-year period, found that the best results of lumbar sympathectomy were obtained when the ischaemia was not too far advanced and particularly if a pedal pulse, however small, could be felt preoperatively. Gillespie (1960) stated that the prime indication for lumbar sympathectomy by itself in obliterative vascular disease is the early ischaemic foot in a patient who gives a long history of vascular trouble and who is unsuitable for direct arterial surgery. Taylor and Calo (1962) did Results of major amputation not find it of any benefit in patients with very severe Mortality rest pain or in limbs threatened by major gangrene. Six patients died in hospital within 1 month of the There would appear to be two groups of patients with operation, from myocardial infarction (3), cerebro- rest pain. In one the pain is minimal and is often vascular accident (2) and pulmonary embolus (1). A relieved by a period of bed rest, probably due to the further 20 patients died during the follow-up period, development of a collateral circulation. These patients an overall mortality of 57.7 per cent. The causes of do well with lumbar sympathectomy and small areas death in 18 of these patients were bronchopneumonia of necrosis heal rapidly. In the other group the pain (9,myocardial infarction (4), cerebrovascular acci- is severe and persistent, and gangrene, when present, dent (3), malignant disease (2), pulmonary embolus may involve the big toe and has often spread to the (2), mesenteric thrombosis (1) and cor pulmonale (1). foot which is usually oedematous. This group does In the case of 2 patients who died at home the cause not respond to lumbar sympathectomy and early of death could not be ascertained. major amputation is required if the limb cannot be salvaged by direct arterial surgery. This paper is conMorbidity cerned with the second group of patients. Wound infection occurred in 3 stumps and secondary Fifty-five per cent of the patients in this series had suture was required in 2. Two patients developed demonstrable ischaemic heart disease and 27 per cent

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Salvage of the lower limb had chronic lung disease. However, no patient was refused direct arterial surgery on the grounds of poor cardiac or pulmonary function. Where an occlusion of the aorto-iliac segment exists, limb salvage prospects are excellent. The object of the operation is to restore blood flow down the profunda femoris artery. A major abdominal operation may not be desirable in patients with cardiac or pulmonary disorder. The cross-over femorofemoral graft is an attractive alternative. It is a relatively simple, speedy operation causing little general disturbance. Baker and Parker (1972), reporting on 7 cases, concluded that the risk of ‘stealing’ from the donor limb seemed much less than might be expected, even in the presence of some iliac disease. They suggested that the indications for this procedure be extended and that it should be considered as an alternative primary procedure in patients who would normally undergo aorto-iliac surgery. With femoropopliteal occlusions a patent popliteal segment is of primary importance when considering bypass grafting. Successful arterial reconstruction is possible in these cases even with a poor distal outflow, as evidenced by occlusion of the tibia1 and peroneal vessels on arteriography. Mannick et al. (1967), reporting on 31 grafts in limbs with the most extreme form of poor outflow (i.e. those with an isolated popliteal segment), had a success rate of 65 per cent. As shown in Table IV, the ‘run-off’ did not appear to have a significant influence on the results. A common cause of failure is the use of too narrow a vein (MacGowan, 1969), and this has been the experience in this series. In such cases Linton and Wilde (1970) suggested a combination of a long proximal endarterectomy with a short vein bypass from the distal end of the endarterectomized artery to the distal popliteal. Koontz and Stansel (1972) using this technique reported a 60 per cent failure rate and suggested that one should explore the other leg in the hope of finding an adequate vein. In our experience exploration of the opposite limb usually reveals a vein as narrow as its fellow. The first 2-3 days after the arterial operation is a critical period during which time there may be a phase of vasoconstriction. There is danger during this period of flap necrosis and destruction of skin grafts. We have, therefore, found it advisable to carry out minor amputations and skin grafts 2-3 weeks after the main operation. It is obviously impossible to make a direct comparison between the group that underwent direct arterial surgery and that which underwent major amputation. It can be seen from Table I I that both groups suffered more or less equally from the tabulated associated disorders. The higher overall mortaIity amongst the amputees could be due to a number of factors. There is no doubt, however, that one of these factors is a loss of the will to survive. This leads to lack of cooperation and immobility, resulting in such complications as bronchopneumonia and pulmonary embolism.

In conclusion it is felt, in agreement with Baddeley et al. (1970), that the results are sufficiently gratifying to justify full investigation and aggressive treatment of patients with seriously ischaemic limbs.

Acknowledgements I am grateful to Mr J. P. Lythgoe and Mr H. J . Done, Consultant Surgeons, for asking me to treat patients admitted under their care, to Mr J. P. Lythgoe and Dr W. G. Owen for reading and criticizing the manuscript and to Mrs B. Scott-Smith for her invaluable secretarial assistance. References BADDELEY R . M., ASHTON F., SLANEY G . and BARNES A. D. (1970) Late results of autogenous vein by-

pass grafts in femoropopliteal arterial occlusion. Br. Med. J. 1, 653-656. BAKER R . and PARKER E. J. c. (1972) Femoro-femoral cross-over grafts. Br. J. Surg. 59, 701-704. EDWARDS E. A. and CRANE c. (1961) Ten-year status after sympathectomy for arteriosclerosis. JAMA 175, 677-679. ERNST c. B., FRY w. J., KRAFT R. 0.and DEWEESE M. s. (1964) The role of low molecular weight dextran in the management of venous thrombosis. Surg. Gynecol. Obsret. 119, 1243-1247. GILLESPIE J. A. (1960) Future place of lumbar sympathectomy in obliterative vascular disease of lower limbs. Br. Med. J. 2, 1640-1642. HARRIS P. L., READ F., EARDLEY A., CHARLESWORTH D., WAKEFIELD J. and SELLWOOD R . A. (1974)

The fate of elderly amputees. Br. J . Surg 61, 665-668. HORTON R . E. (1974) Use of the reversed saphenous vein graft in the treatment of gangrene. Ann. R . Coll. Surg. Engl. 54, 165-1 75. HUNTER-CRAIG I., VITALI M. and ROBINSON K. P. (1970) Long posterior-flap myoplastic below-knee amputation in vascular disease. Br. J. Surg. 57, 6265. HUSNI E. A . (1967) The edema of arterial reconstruction. Circulation 35 (Suppl.) 169-173. KOONTZ T. J. and STANSEL H. c . (1972) Factors influencing patency of the autogenous vein-femoropopliteal by-pass graft. An analysis of 74 cases. Surgery 71, 753-759. LINTON R . R . and WILDE w . L. (1970) Modifications in the technique for femoropopliteal saphenous vein by-pass autografts. Surgery 67, 234-248. MACGOWAN w . A. L. (1969) A report of fifty consecutive autogenous vein by-pass operations for femoropopliteal obstructions. Br. J. Surg. 56, 575-579. MANNICK J. A., JACKSON B. T., COFFMAN J. D. and HUME D. M. (1967) Success of by-pass vein grafts in patients with isolated popliteal artery segments. Surgery 61, 17-25. MARTIN P., RENWICK s. and STEPHENSON c . (1968) On the surgery of the profunda femoris artery. Br. J. Surg. 55, 539-542.

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Y. N. Yogasundram MINKEN s. L., DEWEESEJ. A . , SOUTHGATE w. A., MAHONEY E. B. and ROB c. G. (1968) Aortoiliac reconstruc-

tion for atherosclerotic occlusive disease. Surg. Gynecol. Obstet. 126, 1056-1060. TAYLOR G. w. (1971) Limb salvage arterial surgery for gangrene. Postgrad. Med. J. 47, 251-156.

w. and CALO A. R. (1962) Atherosclerosi of arteries of lower limbs. Br. Med. J. 1, 507-51( VAUGHAN B. F., SLAVOTINEK A. H. and JEPSON R. E (1970) Edema of the lower limb after vascula operations. Surg. Gynecol. Obstet. 131, 282-29C

TAYLOR G.

Single Case Reports During the past three years it has been the policy of the Editorial Board not to accept single case reports unless of unusual clinical or scientific interest. To conserve adequate space for the more major contributions that readers generally prefer, this restriction will remain, but at the same time the Editorial Board hopes that it will continue to receive reports of single cases that fulfil these criteria. It is this intrinsic significance of the case, rather than a review of the literature, which is of importance, and such material will always be carefully considered for publication.

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Salvage of the lower limb.

This is a retrospective study of 80 patients with 94 severely ischaemic lower limbs treated over a period of 6 years. Arterial reconstruction was poss...
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