TOURNIQUET OCCLUSION TECHNIQUE FOR TIBIAL ARTERY RECONSTRUCTION

Purpose: Vascular clamps, vessel loops, and intraluminal occluding dev ices used to control tibial and pedal vessels can be injurious and may fail to occlude heavily calcified arteries. In an effort to prevent i njury to these small arteries, we have investigated the safety and eff icacy of thigh pneumatic tourniquet occlusion for distal vascular cont rol during infrapopliteal reconstruction. Methods: During an 18-month period, 88 tibial or pedal arterial reconstructions were performed on 80 patients (mean age 75 years) by the tourniquet technique. Data rega rding indications for operation, preoperative evaluation, intraoperati ve findings, surgical technique, and early outcome were recorded prosp ectively. Results: Sixty percent of patients were diabetic: 36% insuli n dependent and 24% non-insulin dependent. The indications for operati on were claudication in 6 (7%), ischemic ulcer in 24 (27%), rest pain in 25 (28%), and gangrene in 33 (38%) patients. Thirty-five percent of operations followed failed ipsilateral infrainguinal reconstructions. The peroneal artery was the target vessel in 38%, anterior tibial in 26%, posterior tibial in 23%, tibioperoneal trunk in 9%, and inframall eolar vessels in 4% of cases. Preoperative analog waveforms and ankle- brachial indexes were used to classify the tibial arteries as complian t, 49%; relatively noncompressible, 30%; and absolutely noncompressibl e, 9%. Twelve percent had no Doppler flow at the ankle level. At opera tion 36 of the target arteries (41%) had mural calcification. Tourniqu et pressures of 200 to 400 mm Hg (mode 250 mm Hg) were applied from 13 to 55 minutes (mean 27.1 +/- 9.1 minutes). All patients were given sy stemic anticoagulants. In 19 limbs (22%) the tourniquet was used to oc clude a patent superficial femoral artery above the proximal (inflow) anastomosis to either the superficial femoral artery (8%), the above-k nee popliteal artery (5%), or the below-knee popliteal artery (9%). He mostasis was adequate in all cases and no alternative occlusive device s were required. There were no significant complications attributable to the use of the pneumatic tourniquet. Conclusion: Tourniquet occlusi on simplifies the infrapopliteal dissection, lessens operating time, i mproves visualization of the distal anastomosis, and removes the poten tial for arterial injury to the target vessel. Arterial calcification and noncompressible tibial arteries do not contraindicate the use of t high tourniquet occlusion. This technique is preferred for all patient s undergoing tibial or pedal artery reconstruction.