In the past we were doing
procedures (operations) which were less often described in the literature as a
last resort to save the ischemic limbs in young smokers with occlusion of the
superficial femoral and popliteal arteries with no or poor distal runoffs.
There were earlier or delayed failures in this group of patients with clinical
diagnosis of Buerger’s disease based on the Shionoya criteria. He have improved the ischemic limb salvage
with the improved medical therapies utilizing Intravenous Injection PGE -1 infusions
and dual anti platelet drugs given over period of 6 months in monthly cycles.
We are now facing a small but a
difficult group of young patients with ischemic limbs (TAO- based on Shionoya
criteria) where there is partial relief of the pain symptoms with non-healing
or poor healing of toe ulcers. They have atrophy of the calf muscles. The ankle
pressures are 30-40 mmHg with portable Doppler probe testing. The ulcers are
usually 0.5 cm in diameter with gangrenous margins and dirty pale looking base.
Some of them have shown dilated veins in the ischemic leg. They are not active
functionally and find it difficult to go for long periods. This group of
patients has shown long or short multi segmental arterial occlusive disease at
more than 3 places.
Here, in such group of patients we
are re-looking at the role of surgical intervention for improvement of the
quality of life, healing of ulcers and complete relief of pain. Profundoplasty,
sympathectomy, Thrombo-endarterectomy with vein patch or bypass with a vein
graft of proximal occlusions are the possibilities. It is well known from the
previous studies that intra arterial thrombolytic therapies downsized (limited)
the operations and achieved attractive limb salvage rates. We are of the
opinion that in similar way, this group of patients with residual symptoms and
pain after Injection PGE-1 infusion therapies (6 cycles) may be benefited by
the limited surgical therapies based on the angiographic findings.
In the recent past we have
performed short segment bypass with vein grafts, limited thrombectomy, lumbar
sympathectomy, Profundoplasty as adjunctive procedures to Injection Prostaglandin infusion therapies with relief of symptoms and limb salvage.
Conclusion: Adjunctive surgical procedures will help a
sub group of patients receiving Injection
PGE-1 infusion therapies (6 cycles) with residual ischemia associated
symptoms or ulcers. There is a need to characterize such patients and
objectively evaluate these selection methods with the help of some kind of
clinical score. There is a need to develop a score for selecting the patients
for such adjunctive procedures.
