DORSALIS-PEDIS ARTERIAL BYPASS - DURABLE LIMB SALVAGE FOR FOOT ISCHEMIA IN PATIENTS WITH DIABETES-MELLITUS

Purpose: Although the technical feasibility of pedal artery bypass for limb salvage is now well established, questions remain about its most appropriate use and its long-term durability. Methods: We reviewed ou r experience over an g-year period in 367 consecutive patients undergo ing 384 vein bypass grafts to the dorsalis pedis for limb salvage. Res ults: Ninety-five percent of the patients had diabetes mellitus. Infec tion complicated ischemia at initial presentation in 55.2% of patients . The preoperative arteriogram demonstrated a patent dorsalis pedis in 362 extremities (92.8%). Four hundred two patients underwent explorat ion for bypass, including 29 patients without demonstrated arteries on the arteriogram but audible pedal Doppler signals. Successful bypasse s were carried out in 357 of 362 cases, where preoperative arteriograp hy demonstrated a patent dorsalis pedis artery (98.6%), 16 of 28 cases explored on the basis of a Doppler signal alone (57%), and 11 of 12 p atients where angiographic status was unknown. Ah procedures were perf ormed with vein: in situ 38.5%, reversed 29%, nonreversed 18%, arm vei n 7%, and composite vein 8%. Inflow was taken from the common femoral artery in 34%, superficial femoral or popliteal arteries in 60%, a pre viously placed graft in 5%, and a tibial artery in 1%. There were seve n perioperative deaths (1.8%) and 21 myocardial infarctions (5.4%). Tw enty-nine grafts failed within 30 days (7.5%), but 19 were successfull y revised. Eight of the 10 failed grafts resulted in major amputation (80%). Over the remaining study period, there were 39 additional graft failures, of which 17 were successfully revised, and 17 additional ma jor amputations. Actuarial primary and secondary patency and limb salv age rates were 68%, 82%, and 87%, respectively, at 5 years' followup. The actuarial patient survival rate was 57% at 5 years. Patency rates were similar for in situ and translocated saphenous vein grafts. Concl usions: Dorsalis pedis arterial bypass is an effective limb salvage pr ocedure with long-term durability comparable to distal vein grafts pla ced into more proximal arteries.