VERY DISTAL BYPASS FOR SALVAGE OF THE SEVERELY ISCHEMIC EXTREMITY

Forty-six bypass grafts to tibial arteries distal to the ankle were pe rformed in 35 patients for salvage of extremities threatened by gangre ne or nonhealing ulcers (grade III, category 5) or ischemic rest pain (grade II, category 4). Most patients (80%) were diabetic, with severe ly calcified arteries, whom previously we would have considered as can didates for primary amputation. All reconstructions were performed wit h autologous saphenous vein. Inflow was from the common femoral artery in 5 (11%), the popliteal artery in 25 (54%), or the mid-tibial arter ies in 16 (35%). Life-table analysis was used to calculate primary pat ency and limb salvage. Results were analyzed according to origin of in flow, outflow, or configuration of the conduit (in situ saphenous vein , n = 29 [63%], reversed saphenous vein, n = 11 [24%], or nonreversed saphenous vein, n = 6 [13%]). Overall cumulative primary graft patency at 2 years for all grafts was 72%, and the cumulative limb salvage ra te was 89% for the same interval. No significant differences were seen in comparing grafts originating from the femoral or popliteal level w ith those arising from the tibial arteries. No significant differences were noted in graft patency or limb salvage among grafts with a poste rior tibial, dorsalis pedis, or plantar artery outflow. No significant difference was noted between in situ saphenous vein grafts and revers ed saphenous vein grafts. A significant decreased primary patency was noted for grafts performed with nonreversed, translocated saphenous ve in. We conclude that bypass grafts to the ankle or foot vessels are be neficial and should be considered for limb salvage in extremities with gangrene, ischemic ulceration, or ischemic rest pain. In our experien ce, in situ saphenous vein grafts or reversed saphenous vein grafts pe rformed similarly, whereas nonreversed saphenous vein grafts have a po orer prognosis. Vessel wall calcification requires a modification in t echnique for performance of these grafts but did not affect long-term performance or limb salvage, and thus should not be considered a contr aindication to vascular reconstruction. The operative microscope was u sed in 61% (28 of 46) of these cases and found useful in creating thes e delicate anastomoses. Additional follow-up is needed to document the long-term results of these very distal reconstructions.