Infrapopliteal arterial reconstruction in the severely ischemic lower extremity. A comparison of long-term results of peroneal and tibial bypasses.

The feasibility of limb salvage with bypasses to the infrapopliteal arterial tree has been established. In this review, our experience with bypasses to the peroneal artery is compared with that to the tibial arteries. Autogenous saphenous veins were employed in 164 limb salvage arterial revascularizations because of gangrene, ischemic ulceration, or rest pain. These were retrospectively analyzed by the life-table method. Femorotibial (137) or femoroperoneal (27) bypasses were performed on the basis of adequate preoperative arteriograms demonstrating the distal arterial tree, but with no popliteal runoff. Overall operative mortality was 6.1%. Initial limb salvage was 71.2 +/- 3.9% following femorotibial bypass and 51.9 +/- 9.6% after femoroperoneal bypass. Five and seven year cumulative limb salvage rates for femorotibial bypass were 48.5 +/5.2% and 43.4 +/- 6.7%; those for femoroperoneal were equivalent at 38.2 +/- 9.9%. Since long-term limb salvage can be realized in a large number of patients by revascularization of the distal arterial tree, primary amputation is seldom indicated. Operative approach to the ischemic limb must be based on a thorough preoperative arteriogram which demonstrates contrast within vessels down to the distal foot. This is almost always seen and arterial reconstruction is usually feasible. Therefore, limb salvage should be attempted in lieu of primary amputation whether tibial or peroneal arteries are visualized on preoperative arteriogram.