Surgical Management
Accepted treatments for lower extremity arterial disease include
nonoperative and operative modalities. Nonoperative options include risk factor
modification, exercise programs, and pharmacologic therapy. Operative options include
endovascular modalities such as intra-arterial thrombolytic therapy, transluminal
angioplasty and stent placement, and surgical procedures such as balloon-catheter
embolectomy, endarterectomy, bypass grafting (primary or revision), and amputation.
Lower extremity arterial reconstruction is performed for severe
disabling claudication and for limb salvage. The choice of operative approach depends
primarily on the location and distribution of arterial occlusions. There are several
surgical approaches to patients with lower extremity arterial insufficiency. For
occlusion distal to the inguinal ligament, the femoral popliteal bypass with autologous
great saphenous vein (reversed) graft is most often the procedure of choice. Graft
patency with this approach is reported to be 59% at 5 years and 38% at 10 years.
[496]
The saphenous vein may be used in situ (i.e.,
not reversed), but this technique is more demanding and requires excision of the
valves to allow adequate flow.
Human umbilical vein and polytetrafluoroethylene grafts can be used when autologous
saphenous vein is unavailable, which is often the case when patients have had previous
coronary artery bypass or lower extremity bypass. The cephalic and basilic veins
from the upper extremities are sometimes used as a graft. Harvesting vein from the
upper extremities has obvious implications with regard to intravenous catheter placement
and the use of regional anesthesia.
In patients with aortoiliac disease who are not candidates for
aortobifemoral bypass because of coexisting medical diseases, an extra-anatomic procedure
(i.e., axillofemoral or femorofemoral bypass) is an alternative approach that is
thought to be a less stressful procedure.[497]
Distal arterial reconstruction with a bypass to the tibial, peroneal, or pedal vessels
is almost exclusively performed for limb salvage. Prosthetic grafts have very high
failure rates and every attempt is made to harvest adequate autologous vein.
