B.  The mortality and patency are 50% at 4–5 years. The limb salvage is 70% at 4 years. If the patient has a reasonable life expectancy and functional status, he should undergo the revascularization.

C.  The mortality, patency, and limb salvage rates are irrelevant in this age group.

Question 5

Which patients would you consider to be inoperable? What treatment options may be offered to this subset of patients?

22.1  Commentary

Indications for revascularization to the tibial vessels are limited to ischemic ulcers, gangrene, and rest pain. The long-term patency of the bypass is affected directly by continued tobacco use, and the patient should be urged to stop smoking. Anticoagulation plays no role as the sole management of this patient. Even though the patient may have asymptomatic contralateral disease, there is no role for further investigation. Angiography may be used to visualize both inflow and outflow sites. In general, the most distal available inflow site is utilized to shorten the length of the graft. Time-delayed imaging may be required to visualize the calf and foot arteries because of reduced flow. The use of magnetic resonance angiography (MRA) has proven to be beneficial in identifying patent lower-extremity arteries, particularly in view of the recent advances in imaging software and hardware.1–3 Finally, high resolution duplex imaging has now become a viable alternative for visualization of inflow and outflow sites with the added advantages of cost reduction, fewer complications associated with angiography, and the ability to identify the least calcified artery segment.4–8 However, both MRA and duplex imaging should only be used as preoperative imaging modalities after they have been validated at each center. [Q1: A, B, C, D]

Increasing focus on the perioperative and long-term management of patients with peripheral arterial disease has identified that all the factors listed in Question 2 can significantly reduce the incidence of cardiovascular events in these patients. These data have beensupportedbylargemulticenterrandomizedprospectivetrials9, 10 Therefore,itbecomes incumbent on the vascular surgeon to also consider these as part of the treatment plan when evaluating a patient with peripheral arterial disease. [Q2: A, B, C, D, E]

Evolution of vascular surgery techniques in the past decade, combined with the availability of an adequate venous conduit, has permitted a liberal and aggressive approach to salvage ischemic limbs caused by advanced atherosclerosis. This approach is epitomized by the construction of arterial bypasses to the terminal branches of tibial vessels.11 However, significant numbers of patients continue to face the threat of a major amputation because of insufficient vein necessary to perform a totally autogenous bypass to one of the

infrapopliteal arteries. In these cases, less durable grafts made of prosthetic material must be used if limb salvage is to be attempted. Accordingly, several adjunctive techniques have been designed in an attempt to improve the poor patency results achieved with prosthetic bypasses. These include the administration of immediate and chronic anticoagulants,12 the construction of a vein patch or cuff at the distal anastomosis to prevent occlusion by intimal hyperplasia,13, 14 and the creation of an arteriovenous fistula to increase graft blood flow in high-outflow-resistance systems.15, 16 Despite initial enthusiasm, the results using cadaveric vein have been poor and resulted in its very limited use.17, 18 [Q3: C] If the poplitealarteryhadbeennotasdiseased,anattemptatsubintimalangioplastywithangiography or with duplex guidance may also be considered.19, 20

The expected long-term mortality of this patient is 24–50% at 4–5 years and is due mostly to myocardial ischemia.21 The expected patency of these techniques is 50–60% at 3–4 years.21–24 The expected limb salvage rates are 70–80% at 3–4 years.21–24 [Q4: B]

Based on these data, we would suggest that there is no role for amputation or sympathectomy in this particular patient. However, if the patient had prohibitive cardiac risks, had nonreconstructable disease, or was already so neurologically impaired that the limb was not of any utility to the patient, then observation, primary amputation, hyperbaric oxygen therapy or perhaps experimental protocols involving angiogenesis factors may be in order.

[Q5]

References

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 2. CambriaRP,KaufmanJA,L’ItalienGJ,etal.Magneticresonanceangiographyinthemanagement of lower extremity arterial occlusive disease: a prospective study. J Vasc Surg. 1997;25: 380-389.

 3. Hingorani A, Ascher E, Markevich N, et al. Magnetic resonance angiography versus duplex arteriography in patients undergoing lower extremity revascularization: which is the best replacement for contrast arteriography? J Vasc Surg. 2004;39(4):717-722.

 4. Ascher E, Mazzariol F, Hingorani A, Salles-Cunha S, Gade P. The use of duplex ultrasound arterial mapping as an alternative to conventional arteriography for primary and secondary infrapopliteal bypasses. Am J Surg. 1999;178:162-165.

 5. Mazzariol F, Ascher E, Salles-Cunha SX, Gade P, Hingorani A. Values and limitations of duplex ultrasonography as the sole imaging method of preoperative evaluation for popliteal and infrapopliteal bypasses. Ann Vasc Surg. 1999;13:1-10.

 6. Mazzariol F, Ascher E, Hingorani A, Gunduz Y, Yorkovich W, Salles-Cunha S. Lowerextremity revascularisation without preoperative contrast arteriography in 185 cases: lessons learned with duplex ultrasound arterial mapping. Eur J Vasc Endovasc Surg. 2000;19:509-515.

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11.Ascer E, Veith FJ, Gupta SK. Bypasses to plantar arteries and other tibial branches: an extended approach to limb salvage. J Vasc Surg. 1988;8:434-441.

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13.Siegman FA. Use of the venous cuff for graft anastomosis. Surg Gynecol Obstet. 1979; 148:930.

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15.Dardik H, Sussman B, Ibrahim IM, et al. Distal arteriovenous fistula as an adjunct to maintain arterial and graft patency for limb salvage. Surgery. 1983;94:478.

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17.Albertini JN, Barral X, Branchereau A, et al. Long-term results of arterial allograft belowknee bypass grafts for limb salvage: a retrospective multicenter study. J Vasc Surg. 2000;31:426-435.

18.Harris L, O’Brien-Irr M, Ricotta JJ. Long-term assessment of cryopreserved vein bypass grafting success. J Vasc Surg. 2001;33:528-532.

19.Hingorani A, Ascher E, Markevich N, et al. The role of the endovascular surgeon for lower extremity ischemia. Acta Chir Belg. 2004;104(5):527-531.

20.Ascher E, Marks NA, Schutzer RW, Hingorani AP. Duplex-guided balloon angioplasty and stenting for arterial occlusive disease: an alternative in patients with renal insufficiency. JVasc Surg. in press.

21.Neville RF, Dy B, Singh N, DeZee KJ. Distal vein patch with an arteriovenous fistula: a viable option for the patient without autogenous conduit and severe distal occlusive disease. J Vasc Surg. 2009 Jul;50(1):83-88.

22.Ascher E, Gennaro M, Pollina RM, et al. Complementary distal arteriovenous fistula and deep vein interposition: a five-year experience with a new technique to improve infrapopliteal prosthetic bypass patency. J Vasc Surg. 1996;24:134-143.

23.Kreienberg PB, Darling RC 3rd, Chang BB, Paty PS, Lloyd WE, Shah DM. Adjunctive techniques to improve patency of distal prosthetic bypass grafts: polytetrafluoroethylene with remote arteriovenous fistulae versus vein cuffs. J Vasc Surg. 2000;31:696.

24.HingoraniAP,AscherE,MarkevichN,etal.Aten-yearexperiencewithcomplementarydistal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses. Vasc Endovascular Surg. 2005 Sep–Oct;39(5):401-409.