Foot
revascularization in patients with critical limb ischemia
(Portuguese
PDF version)
Airton
Delduque Frankini1, Marcus Vinicius C. Pezzella2
1.
Vascular surgeon, Hospital Santa Casa de Misericórdia, Porto
Alegre. Doctor of Medicine, Escola Paulista de Medicina, Universidade
Federal de São Paulo. Leading Member and Specialist, Brazilian
Society of Angiology and Vascular Surgery.
2. Vascular surgeon, Hospital Mãe de Deus,
Porto Alegre. Specialist in vascular surgery, Brazilian Society of
Angiology and Vascular Surgery.
Correspondence:
Airton Delduque Frankini
Rua Quintino Bocaiúva, 1290/502
CEP 90440-050 - Porto Alegre - RS
Tel.: +55 51 3332.2410/3222.2716
E-mail: frankini.voy@zaz.com.br
ABSTRACT
Objectives:
The aim of this paper is to evaluate the results of foot arteries
revascularization (dorsalis pedis, retromalleolar posterior tibial
and medial plantar) in patients with critical limb ischemia.
Methods:
Of 190 saphenous vein bypass performed in patients with critical
limb ischemia, distal anastomosis was performed in the arteries
of the foot in 43 procedures (22.6%): 23 dorsalis pedis (53.5%),
16 retromalleolar posterior tibial (37.2%), and four in the medial
plantar artery (9.3%). Trophic lesions were present in 40 feet (93.0%),
and diabetes mellitus was the most frequent associated disease (78.0%).
The saphenous vein was used in situ in 36 cases (83.7%).
Results:
The rate of limb salvage was 81.4% at 30 days postoperative. Eight
major amputations (18.6%) were recorded: three cases with patent
bypass, due to progressive infection or gangrene, three cases with
thrombosis of the bypass, due to poor outflow, and two cases with
ligation of the bypass due to bleeding from the distal anastomosis
caused by serious infection. Two deaths (4.6%) were registered,
both with patent bypass. Long-term follow-up showed patency of 58.1%
and 39.5% at 1 and 3 years, and rates of limb salvage of 55.8% and
46.5% in the same period.
Conclusion:
We conclude that these procedures for revascularization of the arteries
of the foot are useful even in the presence of gangrene, because
of the high rate of limb salvage.
Key
words: arteriosclerosis obliterans, tibial arteries, revascularization
Palavras-chave: arteriosclerose obliterante, artérias
da tíbia, revascularização.
J
Vasc Br 2002;1(3):193-200
INTRODUCTION
Critical
lower limb ischemia has been a constant treatment challenge for vascular
surgeons. Complaints such as foot pain at rest, gangrene of the toes
or painful ulcers with poor healing at the ankles are generally found
in critical ischemia patients1-3 and caused
by progressive arteriosclerosis. Attempts to relieve the symptoms are
directed at increasing irrigation to the foot, as the only way to relieve
ischemic rest pain and offer sufficient circulation to allow delimitation
of necrotic lesions and healing of amputated areas of the foot or of
ulcerated lesions.
With the
aim of increasing irrigation to the foot, many authors have proposed
revascularization techniques increasingly close to the foot itself,4-16
on the basis of precise information derived from the angiographic study
of the irrigation of the foot17-19 or,
more recently, from duplex ultrasound evaluation.20,21
The aim
of the present study is to review the authors' experience of revascularization
of the arteries of the foot in chronic critical lower limb ischemia
patients, in immediate, short-term and long-term follow-up, defined
as up to 30 days postoperative, from 31 days to six months and greater
than six months, respectively.
PATIENTS
AND METHODS
A retrospective
review was carried out between October 1988 and May 2002 of records
relating to 41 arteriosclerosis obliterans patients, in which a total
of 43 distal revascularization procedures were performed in arteries
of the foot. All presented with chronic critical ischemia as defined
in the literature:1-3 40 cases (93.0%) of
trophic lesion and three cases (7.0%) of pain at rest. The trophic lesions
included gangrene in one or more toes in 34 cases, 16 of which with
presence of bacterial infection, and ulcerated lesions of the foot in
six cases, two of which with purulent secretion.
The predominance
of male patients (85.4%) and the average age of 63 years (range: 41
to 85) are related to the arteriosclerotic etiology of the occlusive
process. Table 1 presents the most frequent associated diseases, including
diabetes mellitus in 32 patients (78.0%). Smoking, described as present
in 36.6% of patients, may be underreported, as no test was used other
than the information supplied by the patient.
 Table
1 - Associated diseases in foot revascularization patients
 |
| Disease |
n.
of patients (%) |
|
| Diabetes
mellitus |
32
(78.0) |
| Hypertension |
23
(56.1) |
| Cigarette
smoking |
15
(36.6) |
| Coronary
artery disease |
9
(21.9) |
| Stroke
sequelae |
4
(9.7) |
| Chronic
renal insufficiency in hemodialysis |
1
(2.4) |
|
In situ
saphenous vein bypass was used in 36 cases (83.7%), in one of which
the lesser saphenous vein was used. In the remaining cases (16.3%),
reverse saphenous vein bypass was chosen, in one of which the lesser
saphenous vein was used. The Chevalier valvulotome was initially used,
but was later replaced with the Ristow and Palazzo valvulotome.22
Proximal
and distal anastomoses were located based on preoperative angiographic
information performed in all the patients. Duplex ultrasound was performed
in some more recent cases with the aim of better defining the distal
bed, as proposed by Ascher et al.21 As
of 1996, this technique has also been employed in certain cases to evaluate
the vein that will be used for the bypass, especially when the lesser
saphenous vein was chosen. The distal diameter of the vein, evaluated
intraoperatively or preoperatively with Duplex ultrasound, was considered
adequate at 2 mm or more. In cases where doubt remained about the condition
of the bypass artery, complementary intraoperative angiography was performed.
In exceptional cases, the choice of artery was changed in accordance
with surgical findings. Figure 1 shows an angiograph suggesting choice
of the dorsalis pedis artery. Intraoperatively, the dorsalis pedis artery
was found to be calcified and of inadequate diameter. The only alternative
was to examine the medial plantar artery (Figure 2), which was found
to present smooth walls and small but adequate diameter for the procedure.
The revascularization was performed using the in situ saphenous vein
from the popliteal artery below the knee (Figures 3 and 4). The postoperative
angiograph showed adequate anastomosis (Figure 5) and increased arterial
diameter, guaranteeing good irrigation to the foot.
Figure
1 - Preoperative arteriography showing dorsalis pedis artery (full)
and medial plantar artery (p), distal view.
Figure
2 - Exploratory surgery of left medial plantar artery shown in arteriography
in Figure 1.
Figure
3 - Left popliteal-medial plantar bypass with in situ saphenous vein
(proximal anastomosis at popliteal artery).
Figure
4 - Sequence of Figure 3, showing incisions for removal of saphenous
vein and distal anastomosis at left medial plantar artery.
Figure
5 - Postoperative arteriography
showing anastomosis of the greater saphenous vein and medial plantar
artery shown in Figure 4, distal view.
Proximal
anastomoses were performed at the femoral artery in 19 cases (44.2%).
Ten in the common femoral artery, seven in the proximal third of the
superficial femoral artery, and two were included in this category because
they were performed in the inguinal region: one in an iliac-profunda
femoral bypass implanted simultaneously, and the other in the superficial
femoral vein implanted 24 hours previously to replace an infected bifurcated
prosthesis. The majority of the proximal anastomoses were performed
in the popliteal artery: 24 cases (55.8%), of which 22 below the knee
and two above. The distal anastomoses were performed in the dorsalis
pedis artery in 23 cases (53.5%), the perimalleolar posterior tibial
artery in 16 cases (37.2%) and medial plantar artery in four cases (9.3%)
(Table 2). It should be pointed out that cases in which the distal anastomosis
was performed at the posterior or anterior tibial artery, even in its
distal third, but not in the locations described above, were not included
in this review.
Table
2 - Proximal and distal anastomoses
in foot revascularization.
In six
cases (13.9%), it was necessary to perform associated arterial surgery
to improve proximal flow in the bypasses: one iliac-profunda femoral
bypass with prosthesis, and five endarterectomies, four in the common
femoral artery and one in the external iliac.
Results
were evaluated on the basis of a physical examination by palpation of
the entire arterialized venous tract, cases in which the in situ saphenous
vein technique was used, and pedal pulses were verified in all the patients.
Absent or reduced pulse in the bypass was considered to be total or
partial occluded, requiring further investigation. In cases where any
doubt remained in relation to the pedal pulse, especially with use of
the reverse saphenous vein, further examination was performed with angiography
and, as of 1996, preceded by duplex ultrasound.
The short
and long-term follow-ups were performed by means of regular consultations,
every three months in the first year and every six months thereafter,
taking into consideration the criteria described above to evaluate the
condition of the bypass. Some patients were contacted by telephone.
Patients who missed two consultations were regarded as lost to follow-up.
A Kaplan-Meyer curve was constructed from the data obtained, as recommended
in the literature.1-3
RESULTS
The immediate
results (up to 30 days postoperative) were good, as they saved 35 limbs
(81.5%) from major amputations at the leg and thigh. If patency is the
criterion, the rate rises to 93.0%, as only three limbs were amputated
as a result of thrombosis of the bypass. Seven total or partial occlusions
(16.3%) were recorded with the patient still hospitalized, allowing
four successful reoperations to be performed, maintaining assisted primary
patency.
Major amputations
occurred in eight cases (18.6%), of which five were at the leg and three
at the thigh. Two amputations at the leg were performed with patent
bypasses in diabetic patients, as a result of progressive infection
of the foot (14th day postoperative) and presence of microangiopathy
(20th day postoperative). The three amputations already mentioned resulting
from thrombosis of the bypass due to poor outflow were performed on
the 7th, 16th and 23rd days postoperative. Of the three amputations
at the thigh, all were in diabetic patients, one with patent bypass
but with progressive gangrene of the foot on the 7th day postoperative,
and two with infection leading to bleeding, consequent ligation of the
bypass and irreversible ischemia, on the 23rd and 26th days postoperative.
Infection
was found in five cases (11.6%), aggravated by bleeding in three cases
(7.0%), in two of which, as mentioned, amputation at the thigh was required.
In the third (nondiabetic) patient, the ligation of the bypass - performed
on the 18th day postoperative - caused pain at rest. The other two cases
of infection, both in diabetic patients, resulted in one amputation
at the leg with patent bypass, as mentioned, and one death from sepsis.
Two deaths
(4.6%) were recorded in this review: one from sepsis, as mentioned,
on the 4th day postoperative and one from acute myocardial infarction
on the 20th day postoperative. Other two patients (4.6%) were diagnosed
with acute myocardial infarction, one in surgery and the other on the
2nd day postoperative, both with good clinical outcome.
Debridements
and minor amputations, involving toes or the front portion of the foot,
were planned preoperatively as a result of tissue involvement and performed
in 32 cases (74.4%). Three debridements were performed on infected or
necrotic ulcers either simultaneously (two cases) or after revascularization
(one case). Twenty-nine minor amputations were performed, 11 simultaneously
with bypass surgery, 15 during the hospitalization period after bypass
surgery, and three in the 24 hours before bypass surgery, due to the
presence of infection in diabetic patients.
Excluding
the events that occurred in the first 30 days postoperative and already
described, the average follow-up period was 11 months, ranging from
one to 108 months. In this period, the following outcomes were recorded:
11 patent bypasses (25.6%), seven thromboses without limb loss (16.3%),
four amputations with thrombosis (9.3%), two amputations without thrombosis
(4.6%), five deaths with patent bypass (11.6%) and three patients lost
to follow-up (7.0%). Table 3 contains this information along with the
average period of follow-up to each outcome.
Table
3 - Long-term follow-up of
foot revascularization patients
|
|
Outcome
|
n. |
% |
Average
follow-up |
|
|
Patent
bypass
|
11 |
25.6 |
17
months |
|
Thrombosis
without limb loss
|
7 |
16.3 |
13
months |
|
Amputation
with thrombosis
|
4 |
9.3 |
10
months |
|
Amputation
without thrombosis
|
2 |
4.6 |
8
months |
|
Death
with patent bypass
|
5 |
11.6 |
18
months |
|
Lost
to follow-up
|
3 |
7.0 |
3
months |
|
The Kaplan-Meyer
actuarial curve for patency shows 69.8%, 58.1%, 41.8% and 39.5%, respectively,
at six months and one, two and three years (Figure 6). The curve for
limb salvage shows 67.4%, 55.8%, 48.8% and 46.5%, respectively, at six
months and one, two and three years (Figure 7).
Figure
6 - Kaplan-Meyer
curve for bypass patency in arteries of the foot.
Figure
7 - Kaplan-Meyer
curve for limb salvage with bypasses in arteries of the foot.
DISCUSSION
Since it
was first proposed for the pedal arteries by Baird et al in 19704
and extended to the arterial branches of the foot by Ascer et al in
1988,6 revascularization of the arteries
of the foot has proved to be a promising option for limb salvage in
patients with chronic critical lower limb ischemia. Revascularization
for critical lower limb ischemia necessarily has the aim of irrigating
the foot, as it is in the foot that the alterations of severe ischemia
are found.1-3 In certain cases, however,
the arteries of the foot themselves become the site for distal anastomoses
in an effort to increase the number of patients that can benefit from
revascularization,4,6-16 hence the term "foot revascularization".
The term can, nonetheless, be questioned in the case of the posterior
tibial artery, which - even in a retromalleolar position - is located
in the ankle. Connors et al.16 recently
used the term perimalleolar to define the dorsalis pedis artery and
the posterior tibial artery behind or distal to the medial malleolus.
The dorsalis pedis is, however, located in the foot. The term, while
not strictly anatomical, nonetheless emphasizes the purpose of the revascularization.
The high
incidence of diabetes mellitus, 78.0% of cases in the present study,
is also found in other studies, varying between 70 and 100%6,7,10-12,14-16
and confirming that, in diabetics, the arteries of the foot, unlike
the arteries of the leg, are frequently spared the sclerotic process.
The literature
is unanimous in the choice of the saphenous vein as the best conduit,
including the lesser saphenous vein option, first proposed in 1987.23,24
The lesser saphenous vein was used in only two of our patients: one
in situ with distal anastomosis at the medial plantar artery, and the
other reversed with distal anastomosis at the retromalleolar posterior
tibial artery. Our reduced use of the lesser saphenous vein can be attributed
to two factors. The subfascial position of the vein requires preoperative
imaging, and it is only since 1996 that we have had the option of duplex
ultrasound to perform this investigation. In addition, the majority
of our revascularizations were performed at the dorsalis pedis artery
(53.5%), and the choice of the lesser saphenous vein would thus require
the change of position of the patient on the operating table, which
is frequently not appropriate.
The use
of the popliteal artery as the location for the proximal anastomosis,
first proposed by Veith et al., in 1981, [25] was chosen in 24 cases
in the present study (55.8%): 22 below the knee and two above. This
option has also been used in approximately 60% of 384 cases by Pomposelli
et al.,12 54% of 46 cases by Quiñones-Baldrich
et al.,11 38% of 157 distal procedures
by Connors et al., [16] 27% of 165 cases by Biancari et al., (15) and
16% of 238 cases by Darling III et al.13
The choice of the popliteal artery above or below the knee as bypass
donor source becomes more frequent with a larger number of diabetic
patients, as became clear in the study of Akbari et al., where the popliteal
artery was used in 26.8% of diabetic patients and 12.0% of nondiabetic
patients.26
In situ
saphenous vein was the most commonly used technique in this study, in
36/43 procedures (83.7%). This is a result of its common use in infrainguinal
revascularization by the authors of this series, especially for distal
anastomosis at the arteries of the leg or foot. It is also the most
used technique in the literature.6,7,10-12,14-16
Caution is required principally in relation to anastomosis at the dorsalis
pedis artery, where parallel incisions for dissection of the vein and
artery may cause cutaneous necrosis of the bypass if the tunnel is made
under it. It has been recommended that the tunnel be made more proximal
to parallel incisions, crossing over the tibia.12
The reverse saphenous vein has also been used by other authors, as in
the present series, especially in short bypasses between the popliteal
artery and arteries of the foot, where proximal and distal diameters
of the vein and artery are more proportional than would be the case
in anastomosis between the femoral artery and the artery of the foot.
Two deaths
(4.6%) were registered in the first 30 days postoperative, both of diabetic
patients, one from sepsis (4th day postoperative) and the other from
acute myocardial infarction (20th day postoperative). Considering the
type of surgery, this could be considered a high rate, but considering
the serious condition of the patients and the associated diseases, such
a rate is acceptable. A similar death rate was recorded by Biancari
et al.15 and Darling III et al.,13
while other series recorded lower rates or no deaths.11,12
Occlusion
of the bypass within the first 30 days postoperative was found in seven
cases (16.3%) in the present study, which is similar to the findings
of Andros et al., (15%)7 Ascer et al. (13%)6
and Harrington et al. (12%),10 and lower
than in the study of Biancari et al. (25%).15
Four cases were recuperated through revision of the bypass (57.1%),
a rate similar to that found by Pomposelli et al. (65.5%).12
The remaining three occlusions, attributed to poor bypass outflow, resulted
in amputation, revealing a high incidence of amputation in case of bypass
failure, as observed by Pomposelli et al.12
Eight cases
(18.6%) resulted in major amputation at the leg and thigh in the immediate
postoperative period. Three of these amputations occurred with patent
bypasses, all in diabetic patients. The cause of these amputations was
progressive infection or gangrene in two cases and the presence of diabetic
microangiopathy in the third, preventing healing of the surgery site.
Amputations with patent bypasses were also found by other authors.10,12
Infection
was found in five cases (11.6%) in the present study, four in diabetic
patients, and only one where infection was present preoperatively in
the lesion of the foot. It can be considered that in four cases the
infection arose as a postoperative complication, as three cases were
operated with gangrene of the toes and one withrest pain. The infection
resulted in bleeding at the distal anastomoses in three cases, all requiring
ligation of the bypasses, two proceeding to amputation at the thigh.
One patient, with patent bypass and infection and gangrene of the foot,
required amputation at the leg on the 14th day postoperative in view
of progressive infection. The final infection case occurred in the patient
who presented with rest pain, on the 4th day postoperative, progressing
to death from sepsis. Complications at surgery sites, either from cutaneous
necrosis or infection, are frequent in this type of procedure, although
in frequencies lower than in the present series.13-14
,15 Infection causing bleeding, found in
three cases in the present study (7.0%), occurred in 1.7% of the 238
procedures performed in the dorsalis pedis artery in the study of Darling
III et al.13 and in 0.5% of the 384 revascularizations
of the same artery in the study of Pomposelli et al..12
A further
complication recorded was acute myocardial infarction, found in three
cases in this review (7.0%), reresulting in one death, as mentioned
above, and of two patients who had responded well to conservative treatment.
Both were diabetics. A high incidence of acute myocardial infarction
was also found in the immediate follow-up period in other studies, ranging
from 4.3 to 10.3%.11,12,15
The long-term
follow-up of foot revascularization cases revealed results not very
different from those in the literature. Patency at one, two and three
years was 58.1%, 41.8% e 39.5%, respectively, similar to the rates recorded
by Abou-Zamzam et al.14 and Harrington
et al.;10 lower than those found by Ascer
et al..6 Darling III et al.,13
Quiñones-Baldrich et al.11 and Connors et al.;16
but higher than in the review of Biancari et al.15
Rate of limb salvage in the present study at one, two and three years
was 55.8%, 48.8% and 46.5%, respectively, similar to the rates found
by Biancari et al.15 and lower than those
of the other authors cited above. In this regard, we can mention the
small sample size (43 procedures) and the number of cases lost to follow-up:
although only three patients, they comprise 7.0% of the total.
Considering
the serious condition presented by patients with chronic critical ischemia,
bearing in mind the high incidence of diabetic patients in this category
of peripheral occlusive disease and recognizing that the arteries of
the foot in general are spared obstructive lesions, distal revascularization
of the foot, via the dorsalis pedis artery and via the retromalleolar
posterior tibial artery or its branches, becomes a good alternative
when it is impossible to construct a more proximal bypass to maintain
continuity with the arteries of the foot. In this review, as in the
references cited, revascularization procedures in arteries of the foot
are shown to be useful in the context of chronic critical ischemia,
with good rates of limb salvage and patency in immediate, short-term
and long-term follow-up.
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