The Evolution of Surgical
Techniques for
Critical Limb Ischemia
Cameron M. Akbari, M.D., M.B.A., F.A.C.S.
Washington Hospital Center
Washington, D.C.

Principles of Limb Salvage
for Tissue Loss
1. Prompt control of infection - drainage,
antibiotics.
2. Evaluation for ischemia.
3. Timely arterial reconstruction if ischemia
present, restore maximal perfusion to the foot.
4. Secondary foot procedures in the fully,
maximally revascularized foot.

Tissue Loss:
Revascularization and Choice of Target Artery
1. Restore maximum perfusion to the foot whenever possible.
2. Preferred target: the first vessel in continuity with the foot,
to provide pulsatile maximal flow.
3. Available autogenous conduit may limit the choice of target
artery for bypass options.
4. Revascularization should be planned with alternative target
and inflow arteries in mind: plan A, plan B, etc.

Open Bypass for Tissue Loss
 The standard – hundreds of reports
 Really good operation in the right hands
 Excellent patency from some centers
 Can be done well in multiple patient
populations, octogenarians, multiple medical
problems, using complex conduits
 Most success measured in patency and limb
salvage

Lower Extremity
Arterial Intervention:
General Principles
Inflow (proximal to inguinal ligament)
Conduit
Outflow

Vascular Intervention:
Inflow Operations
Aorto-Bifemoral Bypass
Ilio-Femoral Bypass
Femoral-Femoral Bypass
Axillo-Femoral Bypass

Aorto-Bifemoral Bypass: Exposure

Aorto-Bifemoral Bypass: Exposure

Aorto-Bifemoral Bypass
End to End to
end side

Aorto-Bifemoral Bypass:
Aortic Anastomosis

Aorto-Bifemoral Bypass: Femoral
Anastomosis

Axillo-Bifemoral Bypass: Axillary
Anastomosis

Axillo-Bifemoral Bypass: Femoral
Anastomosis

Axillo-Bifemoral Bypass:
Cross-Femoral

Inflow Operations:
Results
Operation Five-year 1° Patency
Aorto-bifemoral 90%
Ilio-femoral 70-85%
Femoral-femoral 60-85%
Axillo-bifemoral 40-80%
Axillo-unifemoral 20-50%

Lower Extremity Bypass
Reversed Vein Graft
Nonreversed (Translocated) Vein Graft
In Situ Vein Graft
Prosthetic
Composite Prosthetic/Vein Graft

Lower Extremity Bypass:
General Principles
Superior Patency of GSV Grafts
Autogenous Grafts Preferred over Prosthetic
High Quality Conduit is Key to Success

In Situ Leg Bypass:
Vein Preparation
Femoral
vein
GSV

In Situ Bypass:
Valve Lysis

Angioscopy
Angioscopic Vein Graft Preparation
Valve Valvulotome Lysed Valve

Lower Extremity Bypass:
Anastomoses
Proximal
anastomosis
Distal
anastomosis

Lower Extremity Bypass:
QUOTED 5 Year Patency Rates – GSV
Above Knee: 80%
Below Knee Popliteal: 70%
Infrageniculate (Tibial): 60%
Paramalleolar: 55%
OVERALL: 50 - 70%

Lower Extremity Bypass:
One Year Results
PREVENT III Multi Center Trial
Survival: 80%
Primary Patency: 70%
Primary Assisted Patency: 60%
Secondary Patency: 55%
1404 patients w/ CLI
All autogenous conduit
“High risk” conduit in 24%
65% infrapopliteal
Conte et al. J Vasc Surg 2006; 43: 742-751

Bypass
100 100
90 90
Cumulative Survival
80 80
Limb Salvage
70 70
60 60
50 50
40 40
30 DM patients 30 DM patients
20 non-DM patients 20 non-DM patients
10 10
0 0
0 10 20 30 40 50 60 0 10 20 30 40 50 60
Time (months) Time (months)
Akbari, et al. Arch Surg 2000

“Successful” Bypass

Open Bypass for Tissue Loss
 The standard – hundreds of reports
 Excellent patencies from some centers
 Can be done well in multiple patient
populations, octagenarians, multiple medical
problems, using complex conduits
 Most success measured in patency and limb
salvage
 Function? Back to work? Rehab?

Quality of Life and
Infrainguinal Bypass
1. Tremendous variation between reports -
mortality, perioperative morbidity
2. At least 3 - 6 months for healing of the foot
3. Most patients return to pre-op status (non-
ambulatory patients remain non-ambulatory)
4. Approximately 40-50% of patients report “back
to normal” at 6 months

Quality of Life
and Infrainguinal Bypass
5. Improvement in symptom outcome measures:
healing of foot ulcers, improved pain measures
6. Better function before bypass is associated with
better function after bypass
7. 75% - 85% of patients who are independent
pre-op remain independent post-op.
8. Limb amputation (after failed bypass) is
associated with the lowest quality of life scores.

Another alternative..

Lower Extremity
Endovascular Interventions:
More Options than Ever
 POBA
 Stenting
 Laser Assisted Angioplasty
 Atherectomy
 Subintimal Angioplasty
 Cryoplasty
 DES

Infrainguinal Endovascular
Procedures
Changing Paradigm – Endovascular
 Endovascular methods rapidly advancing
 Immediate symptom relief for claudicators
 Excellent immediate success
 Encouraging long-term patency and limb
salvage, paralleling surgical results, from some
centers
 But…

“Successful Endo”

“Successful” Endo
1 Month later

So…
Endovascular versus Open Bypass
for Tissue Loss:
HOW TO DECIDE

Endovascular versus Open Bypass:
Choice
 Patient Considerations
 Lesion Considerations
 One Other Consideration
The test of a first rate intelligence is the ability
to hold two opposed ideas in mind at the same time
and still retain the ability to function.
- F. Scott Fitzgerald

Endovascular versus Open Bypass:
Patient General Considerations
 Functional Status
 Ambulatory, Non-ambulatory, Bedridden
 Co-morbidities
 Differentiate between significant and non-significant
 Diabetes

Endovascular versus Open Bypass:
Patient Specific Considerations
 Availability of Conduit
 Ipsilateral Saphenous Vein
 Status of other leg and contralateral GSV
 Degree of Tissue Loss
Can you restore pulsatile flow?
Can you afford not to?

Endovascular versus Open Bypass:
Lesion Considerations: The “L’s”
 Location
 Iliac, Femoro-popliteal, Tibial
 Length
 Lumen
 Occlusion vs. Stenosis; Calcified
 Levels – multilevel vs. single level
 Likelihood of short, intermediate, long-term
patency

64 yo ambulatory independent woman with ESRD,
known CAD, right forefoot gangrene – needs TMA

64 yo ambulatory independent woman with ESRD,
known CAD, right forefoot gangrene – needs TMA

64 yo ambulatory independent woman with ESRD,
known CAD, right forefoot gangrene – needs TMA

Bypass versus Endovascular:
Look at the Patient, not just the foot

94 yo ambulatory independent man, healthy except
for mild diabetes, foot ulcer – needs arthroplasty

Follow up 2 month Duplex

64 yo diabetic man with one year history of
foot ulcer. Fully ambulatory.

1 year

6 month Follow up Duplex
*
*Foot remains healed one year later

Endovascular versus Open Bypass:
One Other Consideration..

A man's got to know his limitations.
Harry Callahan
1973

Bypass vs. Endo
*
*
#
#
*61% w/ tissue loss
Kudo et al. JVS 2006; 44: 304-313 # 68% w/ tissue loss

Bypass vs. Endo
* Primary patency < 20% at 5 years
Kudo et al. JVS 2006; 44: 304-313

Bypass versus Endo
Pomposelli, et al. J Vasc Surg 2003

Summary
 Endovascular procedures below the inguinal
ligament are here to stay, and the applications
and results are improving every day. The results
are excellent in the right hands.
 Open bypass procedures below the inguinal
ligament are here to stay. The results are
excellent in the right hands.

Summary
 The choice between open and endovascular
revascularization is based on multiple
considerations, weighed together.

Summary
 Open versus endovascular procedures for
tissue loss is not appropriate.
 Rather, we should be talking about open and
endovascular procedures, as in (e.g.) statins and
beta blockers.

Thank You