Pedal and distal lower leg bypasses with a distal arteriovenous fistula.

In forty patients 41 feet were revascularised by means of distal tibial (the distal 10 cm of the lower leg) (17) or pedal bypasses (24). Angiographically the preoperative state was best defined as a lower leg block (LLB); All three arteries showing occlusions at several levels, leaving only isolated functioning arterial segments in the distal leg or foot with relatively good femoral and popliteal arteries. As might be expected this condition was mainly found in diabetics (75%). Only feet with severe rest pain (4) or rest pain with gangrene (37) were operated upon. To improve the distal outflow a side-to-side arteriovenous fistula (AVF) was added to the distal anastomosis. With a mean follow-up of 21 months (1-40 months) the limb salvage rate was 79% and the patency rate 67%. Special problems were experienced with cellulitis of the foot, causing the loss of three feet despite an open bypass and sufficient revascularisation. Furthermore, occlusion of the bypass after healing of the lesion did not necessarily mean a recurrence of gangrene. As this series shows, even in angiographically apparently hopeless cases, a bypass to the foot can prevent an otherwise unavoidable amputation.