Role of adjunctive surgical therapies during or after Injection PGE-1 infusion therapies (cycles) for relieving the residual symptoms (pain), ulcer healing and limb salvage.

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.