Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia

Frank J. Veith, Sushil K. Gupta, Kurt R. Wengerter, Jamie Goldsmith, Steven P. Rivers, Curtis W. Bakal, Alan M. Dietzek, Jacob Cynamon, Seymour Sprayregen, Marvin L. Gliedman

Research output: Contribution to journalArticle

183 Citations (Scopus)

Abstract

From January 1, 1974 to December 31, 1989, we treated 2829 patients with critical lower-extremity ischemia. In the last 5 years, 13% of patients had therapeutically significant stenoses or occlusions above and below the groin, while 35% had them at two or three levels below the inguinal ligament. Unobstructed arterial flow to the distal half of the thigh was present in 26% of patients, and 16% had unobstructed flow to the upper third of the leg with occlusions of all three leg arteries distal to this point and reconstitution of some patent named artery in the lower leg or foot. In the last 2 years, 99% of all patients with a threatened limb and without severe organic mental syndrome or midfoot gangrene were amenable to revascularization by percutaneous rransluminal angioplasty (PTA), arterial bypass, or a combination of the two, although some distal arteries used for bypass insertion were heavily diseased or isolated segments without an intact plantar arch. Limb salvage was achieved and maintained in more than 90% of recent patient cohorts, with a mean procedural mortality rate of 3.3%. Recent strategies that contributed to these results include (1) distal origin short vein grafts from the below-knee popliteal or tibial arteries to an ankle or foot artery (291 cases); (2) combined PTA and bypass (245 cases); (3) more distal PTA of popliteal and tibial artery stenoses (233 cases); (4) use of in situ or ectopic reversed autogenous vein for infrapopliteal bypasses, even when vein diameter was 3 to 4 mm; (5) composite-sequential femoropopliteal-distal (PTFE/vein) bypasses; (6) reintervention when a procedure thrombosed (637 cases) or was threatened by a hemodynamically significant inflow, outflow, or graft lesion (failing graft, 252 cases); (7) frequent follow-up to detect threatening lesions before graft thrombosis occurred and to permit correction of lesions by PTA (58%) or simple reoperation; and (8) unusual approaches to all infrainguinal arteries to facilitate secondary operations, despite scarring and infection. Primary major amputation rates decreased from 41% to 5% and total amputation rates decreased from 49% to 14%. Aggressive policies to save threatened limbs thus are supported.

Original languageEnglish (US)
Pages (from-to)402-412
Number of pages11
JournalAnnals of Surgery
Volume212
Issue number4
StatePublished - Oct 1990

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Disease Management
Lower Extremity
Angioplasty
Ischemia
Arteries
Veins
Tibial Arteries
Transplants
Popliteal Artery
Leg
Groin
Amputation
Foot
Pathologic Constriction
Thrombosis
Extremities
Limb Salvage
Gangrene
Polytetrafluoroethylene
Thigh

ASJC Scopus subject areas

  • Surgery

Cite this

Veith, F. J., Gupta, S. K., Wengerter, K. R., Goldsmith, J., Rivers, S. P., Bakal, C. W., ... Gliedman, M. L. (1990). Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia. Annals of Surgery, 212(4), 402-412.

Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia. / Veith, Frank J.; Gupta, Sushil K.; Wengerter, Kurt R.; Goldsmith, Jamie; Rivers, Steven P.; Bakal, Curtis W.; Dietzek, Alan M.; Cynamon, Jacob; Sprayregen, Seymour; Gliedman, Marvin L.

In: Annals of Surgery, Vol. 212, No. 4, 10.1990, p. 402-412.

Research output: Contribution to journalArticle

Veith, FJ, Gupta, SK, Wengerter, KR, Goldsmith, J, Rivers, SP, Bakal, CW, Dietzek, AM, Cynamon, J, Sprayregen, S & Gliedman, ML 1990, 'Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia', Annals of Surgery, vol. 212, no. 4, pp. 402-412.
Veith FJ, Gupta SK, Wengerter KR, Goldsmith J, Rivers SP, Bakal CW et al. Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia. Annals of Surgery. 1990 Oct;212(4):402-412.
Veith, Frank J. ; Gupta, Sushil K. ; Wengerter, Kurt R. ; Goldsmith, Jamie ; Rivers, Steven P. ; Bakal, Curtis W. ; Dietzek, Alan M. ; Cynamon, Jacob ; Sprayregen, Seymour ; Gliedman, Marvin L. / Changing arteriosclerotic disease patterns and management strategies in lower-limb-threatening ischemia. In: Annals of Surgery. 1990 ; Vol. 212, No. 4. pp. 402-412.
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abstract = "From January 1, 1974 to December 31, 1989, we treated 2829 patients with critical lower-extremity ischemia. In the last 5 years, 13{\%} of patients had therapeutically significant stenoses or occlusions above and below the groin, while 35{\%} had them at two or three levels below the inguinal ligament. Unobstructed arterial flow to the distal half of the thigh was present in 26{\%} of patients, and 16{\%} had unobstructed flow to the upper third of the leg with occlusions of all three leg arteries distal to this point and reconstitution of some patent named artery in the lower leg or foot. In the last 2 years, 99{\%} of all patients with a threatened limb and without severe organic mental syndrome or midfoot gangrene were amenable to revascularization by percutaneous rransluminal angioplasty (PTA), arterial bypass, or a combination of the two, although some distal arteries used for bypass insertion were heavily diseased or isolated segments without an intact plantar arch. Limb salvage was achieved and maintained in more than 90{\%} of recent patient cohorts, with a mean procedural mortality rate of 3.3{\%}. Recent strategies that contributed to these results include (1) distal origin short vein grafts from the below-knee popliteal or tibial arteries to an ankle or foot artery (291 cases); (2) combined PTA and bypass (245 cases); (3) more distal PTA of popliteal and tibial artery stenoses (233 cases); (4) use of in situ or ectopic reversed autogenous vein for infrapopliteal bypasses, even when vein diameter was 3 to 4 mm; (5) composite-sequential femoropopliteal-distal (PTFE/vein) bypasses; (6) reintervention when a procedure thrombosed (637 cases) or was threatened by a hemodynamically significant inflow, outflow, or graft lesion (failing graft, 252 cases); (7) frequent follow-up to detect threatening lesions before graft thrombosis occurred and to permit correction of lesions by PTA (58{\%}) or simple reoperation; and (8) unusual approaches to all infrainguinal arteries to facilitate secondary operations, despite scarring and infection. Primary major amputation rates decreased from 41{\%} to 5{\%} and total amputation rates decreased from 49{\%} to 14{\%}. Aggressive policies to save threatened limbs thus are supported.",
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