The tourniquet revisited as an adjunct to lower limb revascularization

Purpose: The purpose of this study was to evaluate the role and efficacy of the tourniquet in lower limb revascularization, Methods: During a 3-year period, 195 patients underwent 205 infrainguinal r econstruction operations in the lower extremity. These patients underwent b ypass with a tourniquet and inflow occlusion (group 1) or bypass without a tourniquet (group 2). The type of infrainguinal reconstruction, tourniquet ischemia time, blood loss, and complications related to tourniquet use were recorded. A subset of patients underwent serial muscle biopsies. Specimens from calf muscle were taken just (1) before application of the tourniquet, (2) before tourniquet release, and (3) once wound closure was initiated, T hese biopsy specimens were studied by histochemical staining and also analy zed for phosphorylase enzyme, a marker for subcellular ischemia. Results: One hundred eleven patients underwent 117 infrainguinal reconstruc tion procedures in which the tourniquet and inflow occlusion were used. The se patients were marched against 84 patients who underwent 88 infrainguinal reconstructions without: the use of the tourniquet, Complete hemostatic co ntrol in group I was obtained in 108 of the procedures (92%). Eight percent of the procedures required minor additional techniques td obtain complete hemostasis; in two instances, the tourniquet tvas removed because it did no t provide hemostasis. Mean tourniquet time was less than I hour for all rec onstruction groups. There were no instances of neurologic deficit, thrombos is of distal vessels, or vascular injury that was related to the use of a t ourniquet. A comparison of the two groups revealed no differences with rega rd to overall blood loss (P = .63) or duration of operation (P = 0.60), obs ervations that reflect the complexity of the cases rather than the use or n onuse of a tourniquet, When tourniquet control was used, we noted a definit e decrease in the time for the distal dissection, because total vascular co ntrol with extensive dissection was unnecessary. Histochemical analysis wit h phosphorylase revealed a conversion of tissue with active enzyme activity to a low level with tourniquet use (P < .05). Conclusion: The use of a tourniquet for lower limb revascularization is saf e and effective and improves visualization of the operative field. Less dis section of the target vessels is required. With a combination of the nonuse of clamps and other occluding; devices, we project a decrease in host hype rplastic response that will in turn, impact favorably on patency rates, The possibility exists that early failure may be prevented by avoiding the app lication of traumatic forces to diseased and brittle or calcified arteries. In this study, tourniquet time had no impact on overall operative procedur al time, although certain phases of the operation were clearly shortened an d facilitated, particularly in complex and difficult reconstructions. Histo chemical changes found in muscle biopsy specimens did not adversely impact patients clinically, but further investigation is required to elucidate sub cellular events.