Sequential Femoral-tibial Bypass Grafting for Limb Salvage FREDRIC JARRETT, M.D., HERBERT A. BERKOFF, M.D., ANDREW B. CRUMMY, M.D.

Bypass grafting to distal lower extremity vessels continues to be associated with a high rate of graft occlusion. By utilizing a sequential side-to-side anastomosis between saphenous vein and popliteal artery in femoral-tibial bypass grafts, runoff can be increased and graft patency thereby improved. Sequential femoral-tibial grafts were employed in seven patients with gangrene, trophic changes, or restpain, all of whom had single-vessel runoff by arteriography. All seven sequential grafts established to a distal vessel in addition to the popliteal artery have remained open for periods of five to 27 months as determined by palpable graft or foot pulses. Two patients underwent below-knee amputation within six months of operation but had patent grafts at the time of amputation. In three patients ischemic ulcers resolved and in two patients toe amputations healed successfully. Sequential bypass grafting is a technique aimed at improving the patency rate of femoral-tibial bypass grafts by augmenting runoff. p ATIENTS WITH THREATENED LIMB-LOSS who are

found to have advanced arteriosclerotic changes in the vessels distal to the popliteal trifurcation present a difficult problem in operative management. Poor runoff resulting in low flow rates through long grafts into small distal arteries augments the technical difficulty of constructing a durable reconstruction. For these reasons among others the patency rate of arterial reconstructions to the tibial and peroneal vessels is lower than that of femoropopliteal reconstructions and the consequent rate of limb loss is higher.37'9-11'14 Nevertheless, bypass grafting to distal lower extremity vessels is an established technique in vascular surgery whose performance is justified as a limb salvage procedure. 1,3,15,16 We have recently described a technique for increasing runoff by performing a side-to-side anastomosis to an isolated popliteal segment with the same vein that is used for the anastomosis to the single distal artery.4 Seven consecutive patients have undergone femoral-tibial bypass grafting with such a sequential Reprint requests: Fredric Jarrett, M.D., University of Wisconsin Hospitals, Department of Surgery, 1300 University Avenue, Madison, Wisconsin 53706. Submitted for publication: December 13, 1977.

From the Departments of Surgery and Radiology, University of Wisconsin Center for Health Sciences, Madison, Wisconsin

anastomosis to an isolated popliteal segment with resultant short-term graft patency in all. Materials and Methods

Seven patients (ages 60-85) underwent femoraltibial bypass grafts because of gangrene or trophic lesions (five patients) or rest pain with pregangrenous changes (two patients). Four were male and three were female. All but one were either diabetic or hypertensive, or both. All had advanced peripheral vascular disease and five had undergone previous aortofemoral reconstruction, lumbar sympathectomies, or amputation of the contralateral limb (Table 1). All patients underwent arteriography with biplanar views and reactive hyperemia as necessary to delineate their distal vessels. All had superficial femoral and proximal popliteal artery occlusions with significant arteriosclerotic changes distal to the popliteal trifurcation so that only one distal vessel was considered suitable for grafting. Profundaplasty was not considered a feasible alternative in any of these patients. Patients were prepared for operation by treatment of diabetes and hypertension and vigorous attention to pulmonary toilette. Ischemic ulcers were treated with local measures, and with systemic antibiotics if cellulitis or inflammation was present. All patients were begun preoperatively on systemic antibiotics which were continued intra- and postoperatively. At operation the single open distal vessel was exposed first to reconfirm its patency. The anterior tibial artery was exposed at its mid or distal third by a longitudinal incision between the tibia and fibula. Access to the posterior tibial artery was gained about 8 cm above the medial malleolus where it exits from under the lowermost fibers of the soleus. The popliteal artery was isolated and mobilized for construction of

0003-4932/78/1100/0685 $00.70 © J. B. Lippincott Company

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JARRETT, BERKOFF AND CRUMMY

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Ann. Surg.

*

November 1978

TABLE 1. Summary of Clinical Information on Seven Patients

Patient

Age

Sex

Diabetes

TBP

1.

73

M

+

-

Operative Indication

Restpain

Previous Vascular

Surgery Femoral poplateal

bypass

Result

Re-explored for thrombus at 24 hours Remains open-27 months Healed toe amp. Remains open -15 months Below-knee amp. at I month for sepsis Remains open -I I months

2.

67

F

+

-

Ulceration

None

3.

70

F

-

+

Ulceration-heel

Embolectomy

4.

70

F

-

+

Ulceration-heel

Lumbar sympathectomy

Healed ulceration Remains open-16 months

5.

85

M

-

-

Restpain

Lumbar sympathectomy

6.

83

M

+

+

Gangrene-toes

None

7.

60

M

+

-

Ulcerationmalleolus

Lumbar sympathectomy aorto-femoral graft

Restpain relieved Remains open-20 months Healed toe amputation Remains open-12 months Poor healing of ulcers Below-knee amputation-5 months Died 13 months after operation

the side-to-side anastomosis. A sufficient length of saphenous vein was harvested from the ipsilateral limb and prepared for use as a bypass graft. One patient's vein was of insufficient length and a 6 mm Dacron® graft was utilized as the proximal portion of the composite graft. For anterior tibial anastomoses the vein graft was passed along the anterior tibial artery by enlarging the opening in the interosseous membrane and the distal popliteal artery was utilized for the sequential anastomosis. When grafting was performed to the distal posterior tibial artery a more proximal portion of the popliteal artery was preferred to allow less angulation of the vein graft. Tunnels were created and all patients were systemically heparinized. The distal arteries were occluded by traction with heavy ligatures rather than with clamps during construction of the distal anastomosis with a running 6-0 or 7-0 polypropylene (Prolene) suture. The vein graft was then passed proximally to lie alongside the popliteal artery, and a side-to-side anastomosis was performed with 6-0 polypropylene, followed by construction of the proximal anastomosis to the common femoral artery. If the vein graft was not of sufficient length to reach the common femoral, the proximal superficial femoral artery, if open, was utilized. All wounds were closed without drainage. Results All seven patients survived. The single composite Dacron-vein graft thrombosed in the immediate postoperative period and reexploration and thrombectomy were required to successfully re-establish flow. All seven grafts have remained open for periods of five to

27 months as determined by palpable graft or distal pulses. One patient underwent below-knee amputation because of an infected heel ulcer one month after grafting, but had an open graft at the time of amputation and ten months subsequently. Two patients successfully healed toe amputations after revascularization, and three additional patients healed ischemic ulcers after revascularization. The remaining patient required below knee amputation five months after grafting because of persistent ischemic ulceration involving tendon.

Discussion Each advance in the technique of revascularization of lower extremity arteries has brought relief from the complications of ischemia to new groups of patients. 1,7.12 Bypass to vessels below the popliteal trifurcation has been successfully performed for several years to relieve ischemic lesions and distal gangrene. Short-term (30 day) patency has varied between 65-80%, and patency at one year between 40-76% in most series.79"'1l Modifications in technique are necessary to improve the patency rate of bypass grafts to small distal arteries. Reconstructions involving vessels in the distal third of the leg also potentially introduce the risk of nonhealing of operative incisions if the reconstruction is unsuccessful. Patients with threatened limb loss from ischemic lower extremity lesions who have both superficial femoral artery occlusions and extensive distal disease are often considered poor candidates for arterial reconstruction and undergo amputation as an initial procedure. We have demanded complete arteriographic

VOl. 188 . NO. 5

BYPASS FOR LIMB SALVAGE

FIGS. la and b. Anteroposterior and lateral views of an arteriogram showing occlusion of the popliteal artery with poor runoff to a small segment of the anterior tibial artery in its proximal portion.

FIGS. 2a and b. Anteroposterior and lateral subtraction views of the ankle

and foot in the same patient showing filling of

the distal

arterior tibial artery through collaterals from the per-

oneal.

687

evaluation with reactive hyperemia and biplane views before deciding a patient was not a suitable candidate for arterial reconstruction. Frequently patients who are deemed inoperable on the basis of severe occlusive disease at the popliteal trifurcation have at least one open tibial vessel in the distal leg which can be demonstrated with complete arteriograms (Figs. 1 and 2). When inflow is established to this vessel by a vein graft, collateral flow to the foot may improve, and vessels in the more proximal limb can fill in a retrograde manner as well. Adequate arteriographic demonstration of the distal arteries can obviate construction of an anastomosis proximal to an unrecognized partial occlusive lesion, and thereby eliminate a potential cause of graft occlusion. Edwards and associates used multiple sequential grafting in several instances and reported encouraging results as compared with single femoral-tibial anastomoses.6 They noted an additive effect on graft flow with the performance of additional anastomoses which they believe contributed to continued patency. We have not customarily obtained flow measurements in our patients because the anastomoses are performed from distal to proximal, and comparison of graft

Ann. Surg. * November 1978 JARRETT, BERKOFF AND CRUMMY flow rates with and without the side-to-side anastomosis this technique on long-term graft patency and limb would involve multiple clamping of an arteriosclerotic salvage. popliteal artery, which we have been loathe to do. In one instance when flow measurements were obReferences tained, there was an increase from 30 cc/min to 90 1. Baird, R. J., Tutassaura, H. and Miyagishima, R. T.: Saphenous cc/min with opening of the side-to-side anastomosis. Vein Bypass Grafts to the Arteries of the Ankle and the Several authors25'9'13 have reported the use of seFoot. Ann. Surg., 172:1059, 1970. 2. Bartley, T. D., Bigelow, J. C. and Page, U. S.: Aortoquential anastomoses for aortocoronary bypass. coronary Bypass Grafting With Multiple Sequential AnastoGrondin' reported a marked increase in blood flow moses to a Single Vein. Arch. Surg., 105:915, 1972. of the proximal aortocoronary vein graft using this 3. Bernhard, V. M., Ashmen, C. S., Evans, W. E., et al.: Bypass Grafting to Distal Arteries for Limb Salvage. Surg. technique, and Bigelow5 reported an arteriographic Gynecol. Obstet., 135:219, 1972. patency at three years which exceeded the figures 4. Berkoff, H. A. and Jarrett, F.: Technique of Sequential using individual vein grafts. Grafts for Peripheral Vascular Reconstructions. Surg. Gynecol. Obstet., 144:922, 1977. Several technical points have been helpful. When5. Bigelow, J. C., Bartley, T. D., Page, U. S., et al.: Long-term ever possible we have avoided placing vascular clamps Follow-up of Sequential Aortocoronary Venous Grafts. Ann. on small distal arteries, and have preferred to use Thorac. Surg., 22:507, 1976. 6. Edwards, W. S., Gerity, E., Larkin, J., et al.: Multiple traction on a small polyethylene catheter for arterial Sequential Femoral-tibial Grafting for Severe Ischemia. occlusion while constructing the distal anastomoses. Surgery, 80:722, 1976. Coronary artery dilators (1.0-2.5 mm) have been useful 7. Garrett, H. E., Kotch, P. I., Green, M. T., et al.: Distal Tibial in assuring patency of the distal artery as well as Artery Bypass with Autogenous Vein Grafts: An Analysis of 56 Cases. Surgery, 63:90, 1968. slightly dilating the vessel distal to the anastomosis. 8. Grondin, C. M. and Limet, R.: Sequential Anastomoses in Magnification loops are used when necessary. Coronary Artery Grafting: Technical Aspects and Early Femoral-tibial bypass has been performed by many and Late Angiographic Results. Ann. Thorac. Surg., 23:1, 1977. surgeons as a limb salvage procedure. Early and late 9. Imparato, A. M., Kim, G. E., Madayag, M. and Haveson, S. P.: graft failure may be attributed to a number of factors The Results of Tibial Artery Reconstruction Procedures. including unrecognized disease distal to an anastomosis, Surg. Gynecol. and Obstet., 138:33, 1974. progression of distal disease, technical errors, and 10. Kahn, S. P., Lindenauer, S. M., Dent, T. L., et al.: Femorotibial Vein Bypass. Arch. Surg., 107:309, 1973. inadequacy of the vein graft. In our estimation, a 1 1. Kaminski, D. L., Barner, H. B., Donighs, J. A., et al.: Femoral common reason for graft occlusion is inadequate Tibial Bypass Grafting. Arch. Surg., 104:527, 1972. runoff due to small, diseased distal vessels as well as 12. Mannick, J. A., Jackson, B. T., Coffman, J. D., et al.: Success of Bypass Vein Grafts in Patients with Isolated the use of a long saphenous vein of small caliber. Any Popliteal Artery Segments. Surgery, 61:17, 1967. technical measures to improve runoff may be expected 13. Moreno-Cabral, R. J., Mamiya, R. T. and Dang, C. R.: Multiple Coronary Artery Bypass Using Sequential Technic. Am. J. to improve both the short and long-term patency of Surg., 134:64, 1977. femoral-tibial bypass grafts. We have utilized a tech- 14. Noon, G. P., Diethrich, E. B., Richardson, W. P., et al.: nique for augmenting runoff by constructing a seDistal Tibial Artery Bypass. Arch. Surg., 99:770, 1969. quential side-to-side anastomosis between saphenous 15. Reichle, F. A. and Tyson, R. R.: Bypasses to Tibial or Popliteal Arteries in Severely Ischemic Lower Extremities. vein and popliteal artery. Short-term results in seven Ann. Surg., 176:315, 1972. consecutive patients have been excellent. Additional 16. Tyson, R. R. and Reichle, F. A.: Femoro Tibial Bypass. Ann. Surg., 170:429, 1969. follow-up will be necessary to evaluate the influence of

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Sequential femoral-tibial bypass grafting for limb salvage.

Sequential Femoral-tibial Bypass Grafting for Limb Salvage FREDRIC JARRETT, M.D., HERBERT A. BERKOFF, M.D., ANDREW B. CRUMMY, M.D. Bypass grafting to...
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