This study was undertaken to assess factors affecting
limb salvage after femorodistal bypass in patients with established
gangrene. From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe
gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients: a single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases,
polytetrafluoroethylene (
PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot
amputation with uncomplicated healing.
Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for
PTFE grafts. In the entire series the operative mortality rate was 1.7%. Age, sex,
hypertension, or
diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoropopliteal or tibial graft did not reduce the likelihood of
limb salvage. Graft patency, however, is prerequisite for
limb salvage, and graft patency can be maintained by
thrombectomy or repetitive bypass. The present study suggests that
limb salvage is possible in as many as two thirds of limbs with established
gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at
limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival.