Limb salvage using bypass to the perigeniculate arteries.

OBJECTIVE: To describe bypass to perigeniculate vessels for limb salvage. DESIGN: Retrospective cohort study. MATERIAL AND METHODS: Between 1995 and 2009, 47 bypass procedures to perigeniculate collateral arteries were performed in 46 patients (15 women, 31 men; median age, 68 years). All patients presented with critical ischaemia (tissue loss in 87.5%, rest pain in 12.5%). Mean ankle brachial index was 0.27 ± 0.17. The site of distal anastomosis was the descending genicular artery (DGA) in 23 bypasses (1 bilateral) and the medial sural artery (MSA) in 24. Proximal anastomosis was to the external iliac artery in 2 cases, common femoral artery in 23 cases, superficial femoral artery in 8 cases, deep femoral artery in 8 cases, above-knee poplitaeal artery in 2 cases, and previous graft in 4 cases. RESULTS: There were four deaths during the immediate postoperative period. Mean follow-up duration was 27 months. Ten patients required major amputation. Mean ankle brachial index post-operatively was 0.60 ± 0.21. At 3 years, primary patency was 74.7 ± 7%, secondary patency was 83.4 ± 8%, and the limb salvage and survival rates were 73.5 ± 7% and 77.4 ± 7%, respectively. CONCLUSION: Bypass to perigeniculate arteries is a viable treatment option for critical limb ischaemia in selected patients.

Inframalleolar bypass grafts for limb salvage.

OBJECTIVE: To report our experience of long-term results of inframalleolar bypass. DESIGN: Retrospective analysis. MATERIALS AND METHODS: We analysed 122 inframalleolar bypasses performed between January 1991 and June 2005 in 116 patients. Most patients were treated for critical ischaemia (97%). The indication for the use of podalic arteries was a lack of tibial arteries with run-off to the foot. The dorsalis pedis was predominantly used for distal anastomoses (62.3%) and the greater saphenous vein (84.4%) as the conduit. The follow-up periods ranged from 1 to 60 months. The endpoints analysed were graft patency, limb salvage, preservation of deambulation and survival rate. RESULTS: The cumulative patency was 58.2% at 3 years and 53.4% at 5 years. The best results were achieved with the devalvulated greater saphenous veins. Limb salvage was 70.0% at 3 years and 50.4% at 5 years, with preserved deambulation rates of 57.3% and 47.1%, respectively. There were 36 major and 45 minor amputations. At 3 years, the survival rate was 50.2% and the surgical mortality 13%. Female sex was associated with worse results for cumulative patency and limb salvage (P<0.01). CONCLUSIONS: In the long term, inframalleolar bypass is a satisfactory option for limb salvage.

The distal zone of the deep femoral artery as the inflow site in femorodistal bypass grafting.

The distal zone of the deep femoral artery has been used as an inflow site for femorodistal bypass grafts. Eleven such bypass grafts were performed in patients who had critical limb ischemia either to avoid a hostile groin (n=7) or because of an insufficient length of vein (n=4). The posteromedial route was used. Two of the 11 grafts had early failure and a third failed at 3 months: redo surgery restored arterial blood flow to the limb in all three patients. The procedure was safe and is a widely applicable, effective alternative that extends the limits of infrainguinal vein bypass grafting.

Prospective comparison of arm veins and greater saphenous veins as infrageniculate bypass grafts.

OBJECTIVES: to compare arm and saphenous veins for infrageniculate bypass grafting. DESIGN: prospective non-randomised study. MATERIALS: two hundred patients, of which 197 had ischaemic tissue loss or rest pain. METHODS: two hundred and eleven infrageniculate vein bypass procedures using 176 greater saphenous veins and 35 arm veins. RESULTS: the cumulative primary graft patency rate at 1-month and 2 years was 80% and 61% for saphenous vein and 89% and 42% for arm vein. The corresponding rates for secondary patency were 84.5% and 68%, and 91% and 57%, respectively. These results corresponded to a relative risk of secondary failure of 1.53 (95% CI 0.71, 3.31) for arm vein grafts. In subgroup analyses, this estimate was 0.93 and 2.1 for primary vs secondary bypasses and 0.38 and 2.06 for single-vein vs spliced-vein bypasses. Among arm veins, cephalic vein grafts performed better than basilic vein grafts. Early mortality was 14% for arm vein and 10% for saphenous vein. CONCLUSION: in the setting of infrageniculate bypass grafting, arm vein grafts are not equivalent to greater saphenous vein grafts, but contribute importantly to a policy of using autologous veins. The possibility of equivalence remains for the arm vein graft that uses a cephalic vein or is a primary procedure.

Resultados das derivaçöes infra-inguinais até segmento isolado de artéria / Results of infra-inguinal by-passes to isolated artery segment

Os autores apresentam sua experiência com 23 casos operados e nos quais foi feita revascularização do membro inferior por meio de derivaçöes em que a anastomose distal foi implantada num segmento isolado de artéria. A perviedade cumulativa no grupo em que foram usadas próteses (7 casos), a taxa foi de 21 'por cento'. Os resultados obtidos quanto à preservação do membro foram elevados, sendo de 81 'por cento' e 87 'por cento' respectivamente para as lesöes estáveis e instáveis.