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20 Diagnostic Evaluation ofArterial Disease inLimb Salvage
261
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Arterial Disease Management
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intheLimb Salvage Patient:
Endovascular andOpen Bypass
MichaelC.Siah, RobertoFerraresi,
AlessandroUcci, AndreaCasini, GiacomoClerici,
andCameronAkbari
21
Introduction
Chronic limb-threatening ischemia (CLTI) represents the most severe manifestation of peripheral
arterial disease (PAD) and is dened by the presence of ischemic rest pain, ulceration, or gangrene. It affects over two million Americans and
is a global problem of increasing prevalence. The
natural history of CLTI is associated with signicant morbidity, mortality, and rising health care
costs approaching $200 billion annually (1–3).
Without revascularization, 20–40% of patients
will require amputation and 6-month mortality is
greater than 20% (4, 5). As a result, the nancial
burden posed by patients with CLTI is massive,
representing a $3 billion cost to the American
health care system annually.
The mainstay of therapy for the management
of CLTI is revascularization in an attempt to
improve perfusion to an affected limb. Medical
therapy is supportive, utilizing lifestyle modica-
M. C. Siah (*)
Vascular Surgery, UT Southwestern,
Dallas, TX, USA
e-mail: michael.siah@utsouthwestern.edu
R. Ferraresi · A. Ucci · A. Casini · G. Clerici
Diabetic Foot Unit, Clinica San Carlo, Paderno
Dugnano, Milano, Italy
C. Akbari
Georgetown University Hospital,
Washington, DC, USA
e-mail: Cameron.Akbari@medstar.net
tion strategies such as smoking cessation, lipid
lowering and cardioprotective medications,
which are known to decrease adverse cardiac
events and mortality in patients with CLTI.
In addition to medical therapy, both open surgery and endovascular therapies are frequently
utilized in restoring perfusion in patients with
CLTI.Over the course of the last 25years, invasive therapies for the treatment of PAD have
changed dramatically. The frequency of bypass
surgery has decreased by 42%, and endovascular
therapeutic utilization has increased more than 3
times (6). As a result of the increase in overall
procedures performed for PAD, amputation rates
have decreased by 29% (6). Ultimately, the
choice of procedure should be individualized
based on the patient’s anatomy, comorbidities,
and preoperative assessment, with the goal being
to provide the most durable procedure with the
least risk.
Open Surgery General
Considerations
The approach to the patient with CLTI and the
decision as to the type of surgical revascularization depend on the patient presentation and the
CLTI classication. The goal of treatment of
ischemia in the CLTI patient is to restore maximal perfusion to the foot and ideally restore a
palpable foot pulse (7). For example, the patient
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_21
263
264
M. C. Siah et al.
with extensive foot ulceration and/or gangrene
will require normal perfusion to the foot for limb
salvage, with the goal being to restore a normal
foot pulse; in order to maximize the chances of
successful limb salvage, targeted revascularization to the specic angiosome should always be
the rst choice. As the majority of these patients
will have diabetes, and because of the pattern of
diabetic vascular disease, this will almost always
require infrainguinal surgical bypass to the target
vessel. Proximal bypass to the popliteal or tibioperoneal arteries may restore foot pulses; however, the characteristic pattern of occlusive
disease in the diabetic patient usually requires
more distal bypass grafting, often to the dorsalis
pedis artery, distal posterior tibial, or plantar
arteries.
In contrast, the patient presenting with ischemic rest pain without tissue loss may be signicantly ameliorated with more proximal
revascularization. This may include femoral endarterectomy with profundaplasty alone in the
patient with concomitant supercial femoral
artery occlusion, or bypass to an isolated popliteal segment.
In most patients, restoration of the foot pulse
usually mandates infrainguinal arterial bypass
grafting. The primary goal of infrainguinal arterial reconstruction in the ischemic foot is to
bypass to an outow artery that is in direct continuity with the foot, thereby restoring normal arterial pressure to the target area. Although proximal
bypass to the popliteal or proximal tibioperoneal
arteries may restore foot pulses, more distal
revascularization is often needed to achieve this
goal, again owing to the pattern of occlusive disease in the diabetic patient. Similarly, although
excellent results have been reported with peroneal artery bypass, the peroneal artery is not in
continuity with the foot vessels and may not
achieve the maximal ow required for healing,
particularly at the forefoot level. Therefore, the
authors believe that peroneal artery bypass should
be reserved for those rare circumstances in which
there is no dorsalis pedis or posterior tibial artery
in continuity with the foot, or when limited
venous conduit length mitigates against more
distal bypass.
Autogenous vein grafting to the dorsalis pedis,
distal posterior tibial, and plantar arteries incorporates knowledge of the anatomic pattern of diabetic vascular disease, satises the fundamental
goal of restoration of the foot pulse, and provides
durable and effective limb salvage (7, 8). Indeed,
extensive experience with arterial reconstruction
to the pedal vessels has established the efcacy,
durability, and safety of these procedures, and
improved limb salvage rates in the diabetic
patient may be directly attributed to the increasing use of pedal bypass (8). Ultimately, the choice
of outow artery should be based on availability
of conduit, the location of the foot ulcer, and the
quality of the outow vessel. For example, in the
patient with an ischemic heel ulcer, rst consideration should be given to the posterior tibial or
plantar arteries if they are patent by preoperative
imaging. However, absence of a posterior tibial
artery should not rule against a dorsalis pedis
bypass, as comparable rates of healing and limb
salvage for heel ulcers have been reported with
the dorsalis pedis artery bypass.
Clinical experience has shown a variety of
adjunctive techniques to be of advantage in
infrainguinal revascularization among diabetic
patients. For example, due to the pattern of lower
extremity diabetic atherosclerotic disease, the
popliteal or distal supercial femoral artery may
be used as an inow site, thereby allowing for a
shorter length of vein to be used and avoiding
dissection in the groin and upper thigh, a common location for wound complications. In addition, the shorter length of saphenous vein obviates
the need for foot extension of the vein harvest
incision, which is parallel to the one required to
expose the paramalleolar and inframalleolar
arteries; this avoids the resultant skin bridge
which may occasionally become ischemic from
undue tension.
Although the vein graft may be prepared as in
situ, reversed, or nonreversed graft, without any
signicant difference in outcome, the authors
believe that size mismatch may best be minimized with either an in situ or nonreversed technique, particularly for grafts originating from the
common femoral artery. Although the valves in
the vein graft may be lysed blindly, some sur-
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265
geons prefer to cut the valves under direct angioscopic guidance using a exible valvulotome.
This also allows for assessment of the saphenous
vein to detect intraluminal abnormalities, and can
help direct endoluminal interventions that
upgrade the quality of the conduit and improve
patency.
Absence of ipsilateral greater saphenous vein
is not a contraindication for bypass; although
prosthetic material may occasionally be used for
more proximal reconstructions, it should seldom,
if ever, be used for extreme distal bypass grafting.
When ipsilateral saphenous vein is not available,
several alternatives exist for autogenous conduit.
Although the contralateral saphenous vein is
an obvious alternative, several considerations
limit its use in the diabetic patient. Contralateral
leg vein may not always be present in this population of patients who often require multiple
cardiovascular interventions. More importantly,
diabetes is a strong risk factor for subsequent
contralateral limb bypass, with almost 60% of
patients requiring contralateral bypass at
3 years. Therefore, the authors’ approach has
been to use arm vein grafts as the rst alternative in the absence of ipsilateral saphenous vein
(9). The cephalic, basilic, or upper arm basiliccephalic loop vein grafts may be harvested.
Once the vein has been harvested, angioscopic
evaluation is crucial, as many of these patients
have undergone multiple venipunctures and
cannulations with resultant scarring and weblike synechiae. Angioscopy allows for detection
and correction of many of these areas, and
allows for precise valve lysis within these thinwalled veins (9).
Active infection in the foot is not a contraindication to paramalleolar bypass grafting, as long
as the infectious process is controlled (10).
Adequate control implies resolution of cellulitis,
lymphangitis, and edema, especially in areas of
proposed incisions required to expose the distal
artery or saphenous vein. Occasionally, severe
circumferential calcication of the distal artery
may also be encountered. Strategies include the
use of special intraluminal bulb-tipped vessel
occluders or tourniquet occlusion, with no
attempts made at endarterectomy or “cracking”
the plaque. Results of bypasses to calcied vessels are comparable to noncalcied vessels
(9–11).
Several reports have summarized the results of
the dorsalis pedis artery bypass, of which the
most recent summarizes a decade-long experience of more than 1000 cases (11, 12). In that
series, 5-year primary patency rates were 57%
with a limb salvage rate of almost 80%, conrming the efcacy and durability of these procedures. Additionally, concern regarding
perioperative morbidity and long-term outcome
in diabetic patients has also been dispelled (12,
13).
Preoperative Surgical
Considerations
Essential to the success of surgical revascularization is appropriate and accurate preoperative
planning. High-quality arteriography should
include visualization of planned target vessels,
localization and extent of disease in the proximal vessels (including aorta and iliac arteries),
and, if needed, pressure measurements across
suspected inow lesions. Based on the pattern
of vascular disease in the diabetic patient, with
sparing of the pedal vessels, the arteriogram
must include the foot vessels in both the lateral
and anterior views for a complete assessment
(Fig.21.1).
Although others have performed distal revascularization based on Duplex ultrasound or CT
angiography alone, the author’s preference is to
always have a high-quality arteriography prior to
any infrainguinal bypass.
Autogenous ipsilateral saphenous vein is the
preferred conduit for all infrainguinal bypass
grafts. High-quality conduit is central to successful bypass and has direct implications for both
short-term and long-term patency results.
Preoperative bilateral saphenous vein mapping
with Duplex ultrasound should always be performed, assessing for caliber and size, phlebitic
changes, wall thickening, and accessory branching (Fig.21.2a, b).
266
ab
M. C. Siah et al.
Fig. 21.1 Lateral and AP arteriogram of the foot. Note
that on the lateral projection, a vessel which resembles the
dorsalis pedis artery is seen (red arrow). However, the AP
Fig. 21.2 Adequate sized great saphenous vein by Duplex (a) in contrast to a nonusable small sized vein (b). Duplex
can also demonstrate previous phlebitic changes or thrombus within the saphenous vein
projection conrms only lateral tarsal runoff (yellow
arrow), and no true dorsalis pedis artery is present
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267
A minimum diameter should be 2mm; experience
has shown that smaller veins will yield poor results. If
the great saphenous vein is inadequate, consideration
may be given to either arm vein or prosthetic graft; if
the former is chosen, Duplex scanning should be performed in the upper extremities as well.
As with any major operation, appropriate medical stabilization and optimization of the patient
should be performed prior to proceeding with surgical revascularization. This may involve cardiac
stress testing, coronary angiography, and echocardiography. Many patients with longstanding foot
ulceration may be nutritionally depleted, and preoperative assessment and intervention may prevent
postoperative wound and systemic complications.
As noted previously, many patients with CLTI
will present with foot ulceration or gangrene,
with concomitant foot infection. Control of infection is mandatory prior to surgical revascularization, to prevent the risk of systemic sepsis,
wound, and graft infection. In the patient with
diabetes, classical signs of infection may not
always be present in the infected diabetic foot
due to the consequences of neuropathy, alterations in the foot microcirculation, and leukocyte
abnormalities. Fever, chills, and leukocytosis
may be absent in up to two-thirds of diabetic
patients with extensive foot infections, and
hyperglycemia is often the sole presenting sign.
Infections should be adequately drained, as diabetic patients simply cannot tolerate undrained
pus or infection. Because most infections are
polymicrobic, cultures should be obtained from
the base or depths of the wound after debridement so that appropriate antibiotic treatment may
ensue. If adequately controlled with antibiotics
and surgical drainage (if necessary), the infectious process can be controlled within 5–7days,
even in patients with systemic sepsis, and subsequent prompt revascularization may ensue.
Surgical Considerations: Inow
Operations
The term inow operation refers to any procedure performed on a vessel at or proximal to the
inguinal ligament, which restores normal ow
into the femoral segment. These include aortobifemoral bypass, iliac-femoral bypass, common femoral endarterectomy, and
profundaplasty, as well as extra-anatomic
bypasses such as axillo- femoral and femoralfemoral bypass. Because they are performed on
larger vessels with expected higher patency
rates, prosthetic grafts are utilized for almost all
inow bypasses. With greater success and application of endovascular procedures, especially in
the aorto-iliac segment, these procedures are
being performed with marked less frequency.
Nevertheless, they continue to be an important
component of the treatment plan for revascularization, especially for endovascular failures and
infections.
Aorto-bifemoral bypass represents the “gold
standard” for patency and durability for inow
operations, with 5-year primary patency surpassing 90%. The aorta is exposed via a midline incision or retroperitoneal incision, and the proximal
anastomosis may be performed to the infrarenal
aorta in almost all cases. Even if there is occlusive disease present, endarterectomy of the infrarenal aorta may be performed, followed by the
proximal anastomosis to the endarterectomized
aorta (Fig.21.3).
Each limb of the graft is tunneled anatomically to the respective groin and the distal
anastomosis is performed to the common femoral artery. The author’s preference is to extend
the anastomosis onto the profunda, so as to
prevent late thrombosis of the limb secondary
to unrecognized stenoses at the profunda or
supercial femoral artery origin. In instances
of redo operations or groin infection, the anastomosis may be performed onto the profunda
directly, with a lateral approach to the profunda, which avoids the femoral region altogether (Fig.21.4).
Because of the challenges associated with percutaneous endovascular treatment of common
femoral artery disease, common femoral endarterectomy and profundaplasty are utilized commonly, and may be combined with concomitant
iliac or supercial femoral-popliteal-tibial angioplasty. The femoral vessels are exposed, and as
the occlusive process often extends proximally to
268
M. C. Siah et al.
Fig. 21.3 Proximal anastomosis of an aortobifemoral
graft sewn to endarterectomized infrarenal aorta. The yellow arrow points to the left renal vein
the external iliac artery, the distal external iliac
artery above the circumex branches is also
exposed (Fig.21.5).
Arteriotomy is made extending onto the pro-
funda and all plaque is removed (Figs.21.6 and
21.7), followed by patch closure with vein, pros-
thetic patch, or bovine pericardium (Fig.21.8).
If concomitant iliac or distal endovascular
intervention is planned, a sheath may be placed
directly through the patch after restoration of
ow (Fig.21.9), and a simple suture used to close
the hole after the sheath is removed.
In some cases, the occlusive process within
the profunda may be too bulky for endarterectomy, or may result in extensive thinning of the
artery. In these instances, a short bypass from the
common femoral to the profunda may be performed, with excellent results (Fig.21.10).
Fig. 21.4 Distal anastomosis of an aortobifemoral graft
sewn to the second profunda segment, approached laterally, in a patient with an infected heavily scarred groin
from a previous femoral-femoral graft. Note the vein
patch onto the profunda (yellow arrow), with the Dacron
graft sewn onto the patch
Although axillo-femoral and femoral-femoral bypasses are associated with lower patency
rates as compared to the aortobifemoral bypass,
their principal advantages lie in the fact that
they are markedly less invasive. By avoiding an
abdominal incision and aortic cross-clamping,
these operations may be performed in high-risk
patients with poor cardiopulmonary reserve; in
some cases, the operation may be performed
under local anesthesia in those patients in whom
general anesthetic is contraindicated. In addition, by virtue of their extra-anatomic location,
they may be utilized in instances of groin sepsis
when placement of a prosthetic graft is
undesirable.
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Fig. 21.7 Following complete thromboendarterectomy.
Note widely patent orice of both the supercial femoral
and profunda arteries
Fig. 21.5 The femoral vessels as well as the distal external iliac artery proximal to the circumex branches (white
arrows) are dissected free prior to femoral
endarterectomy
Fig. 21.8 The arteriotomy is closed with a bovine pericardial patch
269
Fig. 21.9 After completion of the patch closure (top
Fig. 21.6 Standard endarterectomy of the common fem-
oral, proximal supercial femoral, and profunda femoris
panel), a sheath may be inserted for iliac or more distal
intervention
arteries, with inset showing plaque removed
270
Fig. 21.10 Vein bypass from the common femoral to the
profunda (white arrow)
Surgical Considerations:
Infrainguinal Bypass
Infrainguinal bypass represents the most commonly performed surgical revascularization
among patients with CLI.Several principles are
noteworthy. Autogenous saphenous vein is the
preferred conduit for all infrainguinal bypass
operations, even to the above-knee popliteal
artery. In addition to its superior primary patency
compared to prosthetic, autogenous vein does not
have the disadvantages of associated with prosthetic graft infection, which can be devastating.
The saphenous vein graft can be prepared in several ways. The simplest is a reversed conguration, in which the vein is harvested off its bed,
reversed, and then placed either subcutaneously
or deep to the muscle and fascia after the proximal anastomosis is performed. Because of the
inherent disadvantage of the size discrepancy
between the smaller distal portion of the vein and
the larger proximal artery, the nonreversed and in
situ techniques may be employed, in which the
valves are rendered incompetent by cutting them
with an atraumatic valvulotome. The nonreversed
translocated technique is identical to the reversed
technique except that the valves are cut, whereas
the in situ technique leaves the vein in the bed,
with mobilization only of the proximal and distal
portions and tributary ligation without harvesting
the vein. In both of these, the larger proximal
vein is utilized for the proximal anastomosis,
allowing for an easier anastomosis both proximally and distally.
M. C. Siah et al.
The type of conguration utilized—reversed,
nonreversed translocated, or in situ—has no
effect on patency, and multiple series have conrmed that all yield virtually identical results
when performed correctly. Ultimately the decision as to the type of conguration should depend
on the surgeon’s experience with each technique
and vein graft size. Our preference is either a
reversed graft when the vein is of a uniformly
large caliber and for shorter bypasses, or nonreversed translocated for smaller veins and for long
bypasses (such as femoral-tibial). If a nonreversed conguration is used, we prefer to inspect
the vein with an angioscope and cut all the valves
under direct angioscopic guidance, which allows
for precise valve lysis without any risk of intimal
injury or retained valve, both of which can have
an adverse effect on patency and outcome
(Fig.21.11).
The vein may be harvested through continuous incision, small “skip” incisions, or endoscopically. There has been increasing enthusiasm for
endoscopic, minimally invasive techniques for
harvest, as it may decrease postoperative recovery time, edema, and wound complications.
However, this should be tempered against the risk
of occult vein injury during harvest, including
vein spasm, which can have implications for
patency. Our preference continues to be harvest
by a continuous incision which is meticulously
created to avoid any skin aps (Fig.21.12). This
allows for careful vein harvest. Periadventitial
papaverine or nitroglycerine injection overcomes
vein spasm and the vein is gently distended with
solution, then harvested off its bed. With careful
incision placement, avoiding skin aps, and with
layered accurate closure, we have found the risk
of signicant wound complications to be minimal. Additionally, we prefer to place all grafts
deep to surgical incisions, such that grafts originating from the femoral artery are tunneled deep
to the muscle and fascia down to the below-knee
popliteal space. This obviates the risk of graft
infection or exposure should a wound complication occur, which is discussed in more detail later
in this chapter.
The proximal and distal anastomoses are
almost always performed end to side. All adven-
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271
Fig. 21.11 Angioscopic evaluation and angioscopic guided valve lysis (labeled)
the anterior aspect, so as to minimize twisting of
the graft (Fig.21.13).
Recognizing the pattern of vascular disease in
diabetes, in which the femoral-popliteal segment
is often spared of the atherosclerotic occlusive
process, shorter bypass grafts to the tibial vessels
with origin from the popliteal or distal supercial
femoral artery may be performed. Extensive
experience has shown that, in the absence of
more proximal occlusive disease, such grafts
yield the same patency results as grafts taken
Fig. 21.12 Exposure and harvest of the saphenous vein
through a continuous incision without aps. Note the vein
is fully exposed, allowing for meticulous harvest and prevention of spasm. The incision is created directly overlying the vein, and no thin aps are created, which
maximizes the chance for successful wound healing
from the common femoral artery. This allows for
reconstruction in those patients with limited
saphenous vein, shortens operative time and incision length, and avoids potentially troublesome
groin wound complications.
As an example of a short bypass graft from the
titia should be removed from the vein at the site
of proposed anastomosis to avoid kinking at the
“heel” of the graft, which can be a cause of subsequent graft stenosis or failure. Redundancy at
the proximal and distal anastomoses should also
be avoided. The graft should have a natural curve
with the native artery, with the anastomosis on
popliteal artery, a typical popliteal to dorsalis
pedis bypass graft is illustrated in Figs. 21.14,
21.15, and 21.16. The saphenous vein is har-
vested from the upper leg and will be translocated
subcutaneously in the lower leg, where no incision has been made, which minimizes the risk of
graft infection with any wound complication
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