Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1990 Oct;212(4):402–414. doi: 10.1097/00000658-199010000-00003

Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia.

F J Veith 1, S K Gupta 1, K R Wengerter 1, J Goldsmith 1, S P Rivers 1, C W Bakal 1, A M Dietzek 1, J Cynamon 1, S Sprayregen 1, M L Gliedman 1
PMCID: PMC1358268  PMID: 2145817

Abstract

From January 1, 1974 to December 31, 1989, we treated 2829 patients with critical lower-extremity ischemia. In the last 5 years, 13% of patients had therapeutically significant stenoses or occlusions above and below the groin, while 35% had them at two or three levels below the inguinal ligament. Unobstructed arterial flow to the distal half of the thigh was present in 26% of patients, and 16% had unobstructed flow to the upper third of the leg with occlusions of all three leg arteries distal to this point and reconstitution of some patent named artery in the lower leg or foot. In the last 2 years, 99% of all patients with a threatened limb and without severe organic mental syndrome or midfoot gangrene were amenable to revascularization by percutaneous transluminal angioplasty (PTA), arterial bypass, or a combination of the two, although some distal arteries used for bypass insertion were heavily diseased or isolated segments without an intact plantar arch. Limb salvage was achieved and maintained in more than 90% of recent patient cohorts, with a mean procedural mortality rate of 3.3%. Recent strategies that contributed to these results include (1) distal origin short vein grafts from the below-knee popliteal or tibial arteries to an ankle or foot artery (291 cases); (2) combined PTA and bypass (245 cases); (3) more distal PTA of popliteal and tibial artery stenoses (233 cases); (4) use of in situ or ectopic reversed autogenous vein for infrapopliteal bypasses, even when vein diameter was 3 to 4 mm; (5) composite-sequential femoropopliteal-distal (PTFE/vein) bypasses; (6) reintervention when a procedure thrombosed (637 cases) or was threatened by a hemodynamically significant inflow, outflow, or graft lesion (failing graft, 252 cases); (7) frequent follow-up to detect threatening lesions before graft thrombosis occurred and to permit correction of lesions by PTA (58%) or simple reoperation; and (8) unusual approaches to all infrainguinal arteries to facilitate secondary operations, despite scarring and infection. Primary major amputation rates decreased from 41% to 5% and total amputation rates decreased from 49% to 14%. Aggressive policies to save threatened limbs thus are supported.

Full text

PDF
402

Images in this article

405Fig. 1.
on p.405

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Andros G., Harris R. W., Salles-Cunha S. X., Dulawa L. B., Oblath R. W., Apyan R. L. Bypass grafts to the ankle and foot. J Vasc Surg. 1988 Jun;7(6):785–794. doi: 10.1067/mva.1988.avs0070785. [DOI] [PubMed] [Google Scholar]
  2. Ascer E., Collier P., Gupta S. K., Veith F. J. Reoperation for polytetrafluoroethylene bypass failure: the importance of distal outflow site and operative technique in determining outcome. J Vasc Surg. 1987 Feb;5(2):298–310. [PubMed] [Google Scholar]
  3. Ascer E., Veith F. J., Gupta S. K. Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage. J Vasc Surg. 1988 Oct;8(4):434–441. [PubMed] [Google Scholar]
  4. Bakal C. W., Sprayregen S., Scheinbaum K., Cynamon J., Veith F. J. Percutaneous transluminal angioplasty of the infrapopliteal arteries: results in 53 patients. AJR Am J Roentgenol. 1990 Jan;154(1):171–174. doi: 10.2214/ajr.154.1.2136784. [DOI] [PubMed] [Google Scholar]
  5. Bandyk D. F., Schmitt D. D., Seabrook G. R., Adams M. B., Towne J. B. Monitoring functional patency of in situ saphenous vein bypasses: the impact of a surveillance protocol and elective revision. J Vasc Surg. 1989 Feb;9(2):286–296. [PubMed] [Google Scholar]
  6. Bartlett S. T., Olinde A. J., Flinn W. R., McCarthy W. J., 3rd, Fahey V. A., Bergan J. J., Yao J. S. The reoperative potential of infrainguinal bypass: long-term limb and patient survival. J Vasc Surg. 1987 Jan;5(1):170–179. doi: 10.1067/mva.1987.avs0050170. [DOI] [PubMed] [Google Scholar]
  7. Berkowitz H. D., Hobbs C. L., Roberts B., Freiman D., Oleaga J., Ring E. Value of routine vascular laboratory studies to identify vein graft stenosis. Surgery. 1981 Dec;90(6):971–979. [PubMed] [Google Scholar]
  8. Brewster D. C., Cambria R. P., Darling R. C., Athanasoulis C. A., Waltman A. C., Geller S. C., Moncure A. C., Lamuraglia G. M., Freehan M., Abbott W. M. Long-term results of combined iliac balloon angioplasty and distal surgical revascularization. Ann Surg. 1989 Sep;210(3):324–331. doi: 10.1097/00000658-198909000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Calligaro K. D., Ascer E., Veith F. J., Gupta S. K., Wengerter K. R., Franco C. D., Bakal C. W., Sprayregen S. Unsuspected inflow disease in candidates for axillofemoral bypass operations: a prospective study. J Vasc Surg. 1990 Jun;11(6):832–837. [PubMed] [Google Scholar]
  10. Calligaro K. D., Veith F. J., Gupta S. K., Ascer E., Dietzek A. M., Franco C. D., Wengerter K. R. A modified method for management of prosthetic graft infections involving an anastomosis to the common femoral artery. J Vasc Surg. 1990 Apr;11(4):485–492. [PubMed] [Google Scholar]
  11. Fogoros R. N., Anderson K. P., Winkle R. A., Swerdlow C. D., Mason J. W. Amiodarone: clinical efficacy and toxicity in 96 patients with recurrent, drug-refractory arrhythmias. Circulation. 1983 Jul;68(1):88–94. doi: 10.1161/01.cir.68.1.88. [DOI] [PubMed] [Google Scholar]
  12. Green R. M., McNamara J., Ouriel K., DeWeese J. A. Comparison of infrainguinal graft surveillance techniques. J Vasc Surg. 1990 Feb;11(2):207–215. [PubMed] [Google Scholar]
  13. Gupta S. K., Veith F. J., White-Flores S. A., Samson R. H., Scher L. A., Weiser R. K., Ascer E. System for widespread application of microcomputers to vascular surgery. J Vasc Surg. 1984 Jul;1(4):601–604. [PubMed] [Google Scholar]
  14. Haimovici H. Patterns of arteriosclerotic lesions of the lower extremity. Arch Surg. 1967 Dec;95(6):918–933. doi: 10.1001/archsurg.1967.01330180066012. [DOI] [PubMed] [Google Scholar]
  15. Leather R. P., Shah D. M., Chang B. B., Kaufman J. L. Resurrection of the in situ saphenous vein bypass. 1000 cases later. Ann Surg. 1988 Oct;208(4):435–442. doi: 10.1097/00000658-198810000-00005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Maini B. S., Mannick J. A. Effect of arterial reconstruction on limb salvage: a ten-year appraisal. Arch Surg. 1978 Nov;113(11):1297–1304. doi: 10.1001/archsurg.1978.01370230087010. [DOI] [PubMed] [Google Scholar]
  17. O'Mara C. S., Flinn W. R., Johnson N. D., Bergan J. J., Yao J. S. Recognition and surgical management of patent but hemodynamically failed arterial grafts. Ann Surg. 1981 Apr;193(4):467–476. doi: 10.1097/00000658-198104000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Perdue G. D., Smith R. B., 3rd, Veazey C. R., Ansley J. D. Revascularization for severe limb ischemia. Arch Surg. 1980 Feb;115(2):168–171. doi: 10.1001/archsurg.1980.01380020036009. [DOI] [PubMed] [Google Scholar]
  19. Reichle F. A., Tyson R. R. Comparison of long-term results of 364 femoropopliteal or femorotibial bypasses for revascularization of severely ischemic lower extremities. Ann Surg. 1975 Oct;182(4):449–455. doi: 10.1097/00000658-197510000-00010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Rivers S. P., Scher L. A., Gupta S. K., Veith F. J. Safety of peripheral vascular surgery after recent acute myocardial infarction. J Vasc Surg. 1990 Jan;11(1):70–76. doi: 10.1067/mva.1990.16624. [DOI] [PubMed] [Google Scholar]
  21. Rivers S. P., Veith F. J., Ascer E., Gupta S. K. Successful conservative therapy of severe limb-threatening ischemia: the value of nonsympathectomy. Surgery. 1986 Jun;99(6):759–762. [PubMed] [Google Scholar]
  22. Samson R. H., Sprayregen S., Veith F. J., Scher L. A., Gupta S. K., Ascer E. Management of angioplasty complications, unsuccessful procedures and early and late failures. Ann Surg. 1984 Feb;199(2):234–240. doi: 10.1097/00000658-198402000-00017. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Veith F. J., Ascer E., Gupta S. K., White-Flores S., Sprayregen S., Scher L. A., Samson R. H. Tibiotibial vein bypass grafts: a new operation for limb salvage. J Vasc Surg. 1985 Jul;2(4):552–557. doi: 10.1067/mva.1985.avs0020552. [DOI] [PubMed] [Google Scholar]
  24. Veith F. J., Gupta S. K., Ascer E., Rivers S. P., Wengerter K. R. Improved strategies for secondary operations on infrainguinal arteries. Ann Vasc Surg. 1990 Jan;4(1):85–93. doi: 10.1007/BF02042697. [DOI] [PubMed] [Google Scholar]
  25. Veith F. J., Gupta S. K., Ascer E., White-Flores S., Samson R. H., Scher L. A., Towne J. B., Bernhard V. M., Bonier P., Flinn W. R. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg. 1986 Jan;3(1):104–114. doi: 10.1067/mva.1986.avs0030104. [DOI] [PubMed] [Google Scholar]
  26. Veith F. J., Gupta S. K., Daly V. D. Femoropopliteal bypass to the isolated popliteal segment: is polytetrafluoroethylene graft acceptable? Surgery. 1981 Mar;89(3):296–303. [PubMed] [Google Scholar]
  27. Veith F. J., Gupta S. K., Samson R. H., Flores S. W., Janko G., Scher L. A. Superficial femoral and popliteal arteries as inflow sites for distal bypasses. Surgery. 1981 Dec;90(6):980–990. [PubMed] [Google Scholar]
  28. Veith F. J., Gupta S. K., Samson R. H., Scher L. A., Fell S. C., Weiss P., Janko G., Flores S. W., Rifkin H., Bernstein G. Progress in limb salvage by reconstructive arterial surgery combined with new or improved adjunctive procedures. Ann Surg. 1981 Oct;194(4):386–401. doi: 10.1097/00000658-198110000-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Veith F. J., Gupta S., Daly V. Management of early and late thrombosis of expanded polytetrafluoroethylene (PTFE) femoropopliteal bypass grafts: favorable prognosis with appropriate reoperation. Surgery. 1980 May;87(5):581–587. [PubMed] [Google Scholar]
  30. Veith F. J., Weiser R. K., Gupta S. K., Ascer E., Scher L. A., Samson R. H., White-Flores S. A., Sprayregen S. Diagnosis and management of failing lower extremity arterial reconstructions prior to graft occlusion. J Cardiovasc Surg (Torino) 1984 Sep-Oct;25(5):381–384. [PubMed] [Google Scholar]
  31. Wengerter K. R., Veith F. J., Gupta S. K., Ascer E., Rivers S. P. Influence of vein size (diameter) on infrapopliteal reversed vein graft patency. J Vasc Surg. 1990 Apr;11(4):525–531. doi: 10.1067/mva.1990.18327. [DOI] [PubMed] [Google Scholar]
  32. Whittemore A. D., Clowes A. W., Couch N. P., Mannick J. A. Secondary femoropopliteal reconstruction. Ann Surg. 1981 Jan;193(1):35–42. doi: 10.1097/00000658-198101000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES