Intraoperative superficial femoral artery balloon angioplasty and popliteal to distal bypass graft: An option for combined open and endovascular treatment of diabetic gangrene

Purpose: The purpose of this study was to evaluate the results of combining intraoperative balloon angioplasty (IBA) of the superficial femoral artery (SFA) with distal bypass graft originating from the popliteal artery as a method of lower extremity revascularization in diabetic patients with gangr ene. Methods Among 380 infrainguinal bypass grafts performed over a 6-year perio d, there were 110 reversed saphenous vein bypass grafts to the tibial or pe dal arteries to treat diabetic patients with gangrene. Diffuse infrainguina l disease was treated with femoral-distal bypass graft (long; n = 46). Popl iteal-distal bypass graft was performed when the inflow femoral artery was not significantly diseased (short; n = 52). Focal SFA stenosis and severe i nfrageniculate disease were treated with combined IBA of the SFA and distal bypass graft originating from the popliteal artery (combined; n = 12). Fol low-up was performed with duplex scan surveillance of both the bypass graft and IBA sites. Treatment groups were compared with life table analysis. Results: There were no perioperative graft failures or amputations. The per ioperative mortality rate was 1% (1 of 110). The 2-year primary patency rat es were similar in the three groups: 72% in the long bypass graft group, 82 % in the short bypass graft group, and 76% in the combined group (P = .8, l og rank test). SEA IBA sites developed recurrent stenosis in two patients, at 7 and 48 months; both were detected with surveillance and treated with p ercutaneous transluminal balloon angioplasty. The overall 5-year rate of pr imary patency was 63%, secondary patency was 78%, limb salvage was 81%, and survival was 35%. There were no significant differences among the three tr eatment groups with respect to these outcomes. Conclusion: Results with the combined procedure were similar to those achie ved with either femoral-distal bypass graft or popliteal-distal bypass graf t without SFA IBA. These data suggest that IBA of the inflow SFA may be com bined with popliteal to distal bypass graft and that this technique is a re asonable alternative to longer, femoral-origin bypass graft in selected dia betic patients with gangrene.