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Objective In the presence of long lesions, in patients with chronic limb threatening ischaemia, a femorodistal bypass is often the only option to avoid major amputation. This study investigated whether targeted bypass to the affected angiosome, according to the angiosome concept definition of direct (DR) and indirect revascularisation (IR), has an impact on wound healing, major amputation rate, and mortality. Methods A retrospective analysis was performed at Ghent University Hospital of 201 non-healing ischaemic wounds (Rutherford categories 5 and 6) requiring femorodistal bypass surgery in 177 patients (61% male, median age 69 years) with a follow up of 36 months. For every patient, the site of the ulcer, the type of bypass, and material were identified. Based on ulcer location and distal anastomosis, the legs were divided into DR and IR. Kaplan–Meier univariable analysis was used to estimate cumulative ulcer healing, leg salvage, survival, and patency. Results DR was performed in 103 legs (51%) and IR in 98 legs (49%), with no difference in comorbidity. The mean wound healing time was seven months. DR did not lead to a higher healing rate. The fastest healing rate was obtained when opting for a DR with an autologous greater saphenous vein (GSV; 90% at 12 months). Cryopreserved allografts also yielded good results, especially for wound healing after IR (85% at 12 months). Major amputation was performed in 28.5% after IR vs. 17.3% after DR (p = .071). There was no difference in mortality rate (36.8% [DR] vs. 41.3% [IR]) (p = .088). Autologous GSV had a longer primary patency, primary assisted patency, and secondary patency (26, 34, and 38 months, respectively) than cryopreserved GSV (12.5, 18, and 24 months, respectively) (p = .002, p = .003, and p = .018, respectively), with no difference between DR and IR. Conclusion Direct or indirect revascularisation performed according to the angiosome concept definition yields similar results with regard to healing rates, limb salvage, and mortality.

A case of bilateral persistent sciatic artery (PSA) aneurysms with thromboembolic complications is presented along with a review of the 167 cases of PSA reported in the world literature. Its embryology, anatomy, clinical features, diagnosis, and treatment are reviewed and provide the following findings: The incidence of PSA is estimated to be from 0.025% to 0.04%, based on angiographic studies. Ages range from 6 months to 89 years, with a mean of 54 years. There is no gender predilection. A PSA was present on the right side in 32%, on the left side in 29%, bilaterally in 22%, and on either side in 18%. The "complete" type of PSA was 69%. Aneurysmal change was present in 46% of all PSAs. Overall, 59% had symptoms, including ischemia in 31% (acute in 14% and chronic in 17%), a gluteal mass in 26% (painful in 10%, painless in 6%, and pulsatile in 13%), gluteal pain in 2%, and ischialgia in 5%. Exclusion of the aneurysm or PSA by surgical or interventional techniques, with a femorodistal bypass as required for the resultant ischemia is currently the treatment of choice.

Infected lower extremity bypass grafts have been associated with high rates of limb loss. Traditionally treatment has included graft excision. To compare aggressive local treatment, without graft removal, with more conventional graft excision, we reviewed 38 consecutive patients with 39 infected lower extremity bypasses treated during the last 10 years. The grafts used were prosthetic in 33 cases, vein in 4, and composite in 2. Median follow-up was 2.7 years. Twenty-eight infected grafts were treated with either complete (14) or partial (14) graft removal. Nine new grafts were placed. Recurrent infection developed in five cases, and two patients died of complications of graft infection. Ten of 20 limbs at risk were lost. Eleven patients with patent bypasses (4 vein, 2 composite, 5 prosthetic) were treated without graft excision. Treatment of five patients in this group included muscle transposition. Five patients were treated with incision and drainage of abscesses, and one had excision of a persistent sinus tract. One patient underwent major amputation 6.3 years after treatment of graft infection. Limb salvage was significantly higher ( p = 0.012, log-rank test) than in patients treated with graft excision. One patient died, and no recurrent infections developed; these were not significant differences compared with those having graft excision. We conclude that aggressive local treatment of infected lower extremity bypass grafts, including drainage, debridement, and muscle transposition may treat infection in selected patients without the need for graft removal and with rates of limb salvage superior to those obtained with excisional therapy. (J Vasc Surg 1992;15:295–305.)

Complete intraoperative postreconstruction angiograms were obtained during 93 reoperations after failed femoropopliteal and femorodistal bypass grafts to evaluate the predictive value of a new method of angiographic runoff assessment. Good runoff was defined as patency of two or three lower leg arteries to the foot, or one patent vessel continuous with an intact anterior or posterior foot arch in femoropopliteal and proximal femorodistal bypasses, and integrity of both arches in low femorodistal bypasses. All other outflow patterns were considered poor. The cumulative 1-year patency rate was 61% with a 79% limb salvage rate after reoperations performed in limbs with good runoff. In reoperations with poor runoff, the patency rate was only 5% with a 22% limb salvage rate. In reoperations with good runoff, an 85% patency rate of vein grafts compared to 43% of prosthetic grafts clearly demonstrated the importance of graft material on early outcome. The improved prediction of early outcome with this new method of angiographic runoff evaluation might allow more rational management of patients with failed infrainguinal grafts. (J VASC SURG 1990;12:131-8.)

This retrospective study compared the results of percutaneous transluminal angioplasty (PTA) with those of infrainguinal bypass procedures in patients with critical arterial ischemia to determine which procedure had superior patency, limb salvage, and durability. The records of 54 patients who underwent 54 PTAs and 56 patients who underwent 63 infrainguinal bypasses (29 femoropopliteal and 34 femorodistal) from 1981 to 1987 were reviewed. In each patient PTA or bypass was the initial vascular procedure. Patients in both groups were comparable with respect to age, sex, and the presence of diabetes, hypertension, obesity, hypercholesterolemia, and smoking. Mean follow-up was 40 months (4 to 88 months) for the PTA group and 28 months (6 to 78 months) for the surgery group. Thirty-nine of the 54 patients (72%) were initially improved after PTA, whereas 15 patients (28%) showed no improvement. During follow-up, 20 initially successful PTAs reoccluded. Thirty-two of 54 patients (59%) underwent subsequent procedures, which included repeat PTA (10) and distal bypass (14). Patency determined by noninvasvie Doppler studies was 18% at 2 years. Limb salvage, which included such secondary procedures, was 78%. Two-year patency for femoropopliteal bypasses was 68% with a limb salvage of 90%. Femorodistal bypasses had a 2-year patency of 47% and a limb salvage of 74%. No perioperative deaths occurred. Twenty-one of the 63 patients (33%) had subsequent procedures, which included thrombectomy (5) and bypass revision (9). In patients treated for limb-threatening ischemia the 2-year patency after femoropopliteal bypass (68%) or femorodistal bypass (47%) is significantly better than that from PTA (18%, p < 0.001). Whereas limb salvage after PTA (78%) was not significantly different from that after femoropopliteal bypass (90%) or femorodistal bypass (74%), the PTA group required a significantly greater number of subsequent procedures compared to the surgery group (59% versus 33%, p < 0.01). The low patency rate and the need for subsequent procedures after PTA indicates that bypass procedures are more durable. (J Vasc Surg 1989;9:698–703.)

The results of 160 infrainguinal bypasses with arm vein grafts were analyzed. Seventy-three arteriograms were reviewed to identify early and late graft defects; arteriographic findings paralleled those described for saphenous vein grafts. Intimal fibrosis during the first postoperative year, observed in 16 grafts, was the most common defect. Aneurysmosis and elongation were rare, resulting in two graft replacements. Patency and limb salvage rates were calculated for 88 single-length femorodistal bypass grafts; the other 72 were inflow (eight) or outflow (22) jump grafts, sequential (eight) and composite autogenous vein grafts (34). The primary and secondary patency rates for single-length grafts were 74% and 80% at 1 year and 51% and 57% at 5 years, respectively. The limb salvage rate at 5 years was 82%. The survival rate for all patients was 44% at 5 years. These findings reconfirm our use of arm veins as bypass grafts when the saphenous vein is unavailable. (J VASC SURG 1986;4:416-27.)

This study was undertaken to assess factors affecting limb salvage after femorodistal bypass in patients with established gangrene. From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients: a single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases, polytetrafluoroethylene (PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot amputation with uncomplicated healing. Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for PTFE grafts. In the entire series the operative mortality rate was 1.7%. Age, sex, hypertension, or diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoropopliteal or tibial graft did not reduce the likelihood of limb salvage. Graft patency, however, is prerequisite for limb salvage, and graft patency can be maintained by thrombectomy or repetitive bypass. The present study suggests that limb salvage is possible in as many as two thirds of limbs with established gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival. (J VASC SURG 1985;2:669-77.)

Residual arteriovenous fistulas are a potential source of morbidity after femorodistal bypass operation has been performed with the in situ great saphenous vein graft. A review of our initial experience with 155 operations in which various methods of intraoperative detection were used showed that fistulas were overlooked in 27 cases (17.4%), causing graft thrombosis in 10 cases (6.4%). After the introduction of a rapid and simple intraoperative test that used retrograde irrigation of the graft, only three superficial fistulas were overlooked in 70 operations (4.2%), with no associated graft thrombosis. The test had no detectable deleterious effects and graft distension pressures were within acceptable limits. (J VASC SURG 1986;4:578-81.)

Mortality and the incidence of myocardial infarction and cerebrovascular lesion have been retrospectively analyzed in patients who have survived 30 days after lower limb vascular reconstruction. These events have been related to the extent of arteriosclerotic lesions in the trifurcation of the popliteal artery (trifurcational disease, TFD) in 368 patients treated consecutively. One hundred fifty-five patients underwent aortoiliac reconstruction, 229 had femorodistal bypass, and 16 underwent both procedures. The median follow-up period was 4.4 years. The mortality rate in male and female patients was increased compared with the expected mortality. This increase was found both in patients with and without TFD. In patients having TFD the mortality was 2.0 times higher than in patients who did not have TFD (p less than 0.001). The difference in the mortality rate persisted after correction for the influence of age, sex, and diabetes mellitus. The higher mortality rate in patients who had TFD was most marked early in the postoperative period and was mainly caused by myocardial infarction. The incidence of myocardial infarction and cerebrovascular events was significantly increased in patients who had TFD compared with those who did not, particularly in the early postoperative period.