J Vasc Surg. 1985
Sep;2(5):669-77.
Infrapopliteal bypass for established gangrene of the forefoot or toes.
Dalsing MC
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 femoro-popliteal 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.
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.
There is always this question, should we do a bypass in a patient with forefoot or toe gangrene? We should in a selected group of patients as this can be useful.
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