INTRAOPERATIVE PREBYPASS ARTERIOGRAPHY FOR INFRAGENICULATE REVASCULARIZATION

BACKGROUND: Selection of the optimal distal target for infrageniculate arterial revascularization remains difficult in patients with multile vel occlusive disease due to poor visualization of the distal vasculat ure by preoperative arteriography. Prebypass, intraoperative arteriogr aphy (IOA) with direct injection of contrast into the infrageniculate arteries may improve distal arterial visualization and bypass target s election. METHODS: One hundred fourteen extremities in 104 consecutive patients requiring infrageniculate. bypass were prospectively studied . All patients underwent preoperative contrast arteriography (CA) of t he aortoiliac and lower extremity arteries using iodinated and/or CO2 contrast and digital subtraction techniques. IOAs were obtained at ope ration to confirm the adequacy of the distal runoff from the predicted bypass target and to identify potentially superior targets. The preop erative plan formulated from the CA was compared to the actual procedu re performed based on the IOA. The CA and IOA were also independently reviewed postoperatively by two blinded vascular surgeons to determine the number of patent vessel segments visualized and the number of seg ments with <50% stenosis. RESULTS: Revascularization was done in 105 o f 114 extremities (92%), whereas amputation was required as the initia l procedure in 9 patients (8%). The IOA altered the operative plan bas ed on the CA in 27 of 144 patients (24%). Changes in the planned bypas s procedures included selection of a more distal anastomotic site in 1 3 of 102 patients (13%), selection of a more proximal anastomotic site in 4 of 102 (4%), selection of a different artery for the distal anas tomosis in 3 of 102 (3%), and amputation rather than bypass in 2 of 10 2 patients (2%) with no suitable distal bypass target on the IOA. The IOA also resulted in bypass rather than planned amputation in 5 of 12 patients (42%) deemed unreconstructable on the preoperative CA. A mean of 13 minutes was required for IOA and an adequate study was obtained on the first attempt in 98 of 144 patients (86%). On postoperative re view, more patent vessel segments but fewer segments with <50% stenosi s were identified on the IOA compared to the CA. CONCLUSIONS: Prebypas s intraoperative arteriography facilitates selection of the optimal di stal bypass target during infrageniculate revascularization and can re sult in initial limb salvage in select patients deemed unreconstructab le by preoperative contrast arteriography. (C) 1997 by Excerpta Medica , Inc.