Annals of the Royal College of Surgeons of England
(I979) vol 6i
ASPECTS OF TREATMENT*
Extended deep femoral angioplasty and lumbar sympathectomy as a limb salvage procedure I M. Stevenson FRCS P N Wake FRCS G J Santer FRCS Walton Hospital, Liverpool
Summary Limb salvage in 27 limbs (26 patients) using the combined operations of extended deep femoral angioplasty and lumbar sympathectomy is described. A successful result was obtained in I4 cases (52%) at 6 months falling to I2 (45%7o) at i6 months. Prediction of outcome and postoperative progress was monitored by the measurement of the leg: arm pressure ratio using the Doppler ultrasound apparatus. No patient with a preoperative ratio of less than 0.3 had a successful result. It is proposed that lumbar sympathectomy is a logical adjunct to surgery in these patients in order to enhance the development of the collateral circulation. Introduction The use of profundoplasty as an alternative to femoropopliteal bypass for the relief of intermittent claudication of the lower limb is now well known" 2. Recently it has been shown that extending the angioplasty as far down the profunda trunk as possible (extended deep femoral angioplasty (EDFA)) may improve the results3. There is also some evidence that the addition of lumbar sympathectomy may be beneficial4. We were therefore interested to determine how effective the combined operations of EDFA and lumbar sympathectomy would be as a limb salvage procedure in patients who were suffering from severe rest pain, limited digital gangrene, and/or ischaemic ulceration for whom arterial reconstruction was the only alternative to major amputation. Materials and methods The operation was performed on 27 limbs (26 patients, i 8 male and 9 female). Age at operation ranged from 48 to 84 years with a
mean of 66.5 years. All patients had severe rest pain, I5 digital gangrene, i o ischaemic ulceration, and 2 both ulceration and gangrene. Before operation translumbar or percutaneous femoral angiography was performled to determine whether or not the run-in to the common femoral artery was adequate and also to assess the degree of run-off as shown by the patency and number of vessels seen below the knee. In addition, a preoperative assessment of the pedal perfusion pressure was made by measuring the leg:arm pressure ratio with the Doppler ultrasound apparatus (Model 802, Park Electronic). The technique used was similar to that described by Yao et al5. In the postoperative period the pressure ratios were measured at intervals in order to determine the correlation between these numerical values and the clinical success or failure of the arterial reconstruction. The result was judged to be successful if relief of rest pain was complete and ischaemic ulcers or digital amputation wounds healed, partially successful if there was a temporary improvement, and a failure if there was no change.
Operative technique The operation is performed through a long vertical groin incision, very much as described by Cotton and Roberts3. The deep femoral artery is extensively mobilised from its origin as far down its course as possible; this varied from 4 to I7 cm (mean 8.5 cm) in this series before healthy artery suitable for the distal anastomosis was reached. After incision a suitable piece of woven Dacron is fashioned
*Fellows and Members interested in submitting articles for consideration with a view to publication in this series should first write to the Editor.
Extended deep femoral angioplasty and lumbar sympathectomy
147
performed for digital gangrene in 5 cases, one of which required split skin grafting. All healed uneventfully. Included in this group were the 4 patients in whom a femoropopliteal bypass was possible, emphasising that run-off was better in this group. The mean preoperative pedal perfusion ratio was o.68 and in all cases there was a significant rise in the postoperative period to a mean of o.8s. Two patients were diabetic. Follow-up to February I978 has been from io months to 25 months with a mean of I5.7 months. Two patients have come to below-knee amputation at Io months and i8 months respectively, one from progressive disease and one with angiographically proven occlusion of the profunda trunk. PARTIALLY SUCCES SFUL
EDFA at conclusion of operation, showing woven Dacron patch extending from common femoral bifurcation for a distance of IO cm down the profunda trunk. and sutured into place as a patch (see figure) and the skin closed with suction drainage. A lumbar sympathectomy is then performed through a standard muscle-splitting incision. We prefer to perform any minor forefoot amputation at this stage rather than delay for two or three weeks as recommended by some'. As advocated by Cotton and Roberts we also omit the endarterectomy, which makes the operation easier and shorter and lessens the risk of distal intimal flap dissection. In only 4 cases would femoropopliteal bypass have been technically possible as an alternative procedure and in one case extensive distal disease made even the performance of EDFA impossible. Results SUCCESSFUL
Seven limbs (26%) showed a temporary improvement, with reduction in rest pain, but complete relief did not occur and 5 patients have since come to amputation, although a below-knee operation was satisfactory in 3 of these. This group of patients had a lower mean preoperative pedal perfusion ratio (o.s6) and the rise in the postoperative period (mean o.62) was also lower than in the successful group. One of these patients was diabetic; relief of his rest pain was sufficient for him to keep his limb until he relapsed at 6 months, when angiography confirmed a blocked deep femoral trunk. FAILURES
Six limbs (2 2 go) showed no improvement and all came to early above-knee amputation. The mean preoperative pedal perfusion pressure ratio was low (0.36) and in no case was there a rise after the operation. This group included the one patient in whom extensive distal disease of the profunda femoris precluded operation. Two patients were diabetic; in one of these the artery thrombosed in the early postoperative period and despite re-exploration patency could not be restored, necessitating high above-knee amputation.
Discussion
The outcome was successful in 14 limbs The elderly patient with chronic lower limb (527C) at 6 months and I2 limbs (45Co) ischaemia presents an increasingly common at I6 months. Local amputation was problem today. There is no doubt that the
I48
I M Stevenson, P N Wake, and G J Santer
results of major amputation are poor and that these patients impose heavy burdens on the ancillary services of the National Health Service7. While claims have been made for successful local amputation with pedal perfusion pressures as low as 35 mm Hg (4.7 kPa)8, this is not a general experience and in any case does not relieve the main symptom of rest pain. There are significant numbers of these patients with disease primarily below the inguinal ligament who are not suitable for femoropopliteal bypass or similar operations. In addition, although disease in the deep femoral artery is often more marked at its origin, it is now recognised that extensive disease may be present without arteriographic signs9. This has been our experience, and in 8 cases (29 7o) it has been necessary to mobilise the artery for over io cm before healthy artery has been reached. Since the aim of deep femoral angioplasty is to increase the blood flow into the collateral circulation, the performance of lumbar sympathectomy as an adjunct to surgery is logical since it has been shown to enhance the development of the collateral circulation10. It is this group of patients who, we believe, are best served by EDFA and lumbar sympathectomy as a means of limb salvage. In previous series attempts to predict the outcome of the operation have been made on the basis of inspection of the distal run-off on the arteriograms. In our experience this, although helpful, is not without inaccuracy and we feel we have had more success in predicting the outcome of operation by using the leg: arm pressure ratio as a measure of
pedal perfusion pressure. No patient with a preoperative ratio of 0.3 or below had a successful result-a total of 5 cases (i8%) in the series-and we would now regard it as unjustifiable to attempt operation in this group of patients. There was no operative mortality in the series, but 8 patients (27%7o) have since died, 4 from coronarv occlusion, 2 from coexistent malignant disease, and 2 from unknown causes. This serves to emphasise that these patients are elderly, with generalised arterial disease, and may also have other disabilities. Salvage of a pain-free limb may make the difference between a mobile and bedridden existence. We are grateful to Mr Paul Atkins and Mr John Littler for allowing us to oiperate on their patients.
References I
2
3
4 5 6
7 8 9 io
Martin, P, Frawley, J, Barabas, A, and Rosengarten, D (1972) Surgery, 71, I82. Martin, P, and Bouhoutsos, J (I977) British Journal of Surgery, 64, I94. Cotton, L T, and Roberts, V C (1975) British Journal of Surgery, 62, 340. Morris-Jcnes, W, and Jones, C D P (I974) American Journal of Surgery, I72, 68o. Yao, S T, Hobbs, J T, and Irvine, W T (i96o) British Journal of Surgery, 56, 676. Yogasundram, Y N (1976) British Journal of Surgery, 63, 37I. Harris, P L, Read, F, Eardley, A, Charlesworth, D, Wakefield, J, and Sellwood, R A, (I974) British Journal of Surgery, 6i, 665. Verta, M J jr, Gross, W S, Van Bellen, B, Yao, S T, and Bergen, J J (1976) Surgery, 80, 729. Buerger, R, Cotton, L T, and Sabri, S (I973) British Medical Journal, 2, 469. Sheperd, J T (1950) Clinical Science, 9, 49.
(I979) vol 6i
ASPECTS OF TREATMENT*
Extended deep femoral angioplasty and lumbar sympathectomy as a limb salvage procedure I M. Stevenson FRCS P N Wake FRCS G J Santer FRCS Walton Hospital, Liverpool
Summary Limb salvage in 27 limbs (26 patients) using the combined operations of extended deep femoral angioplasty and lumbar sympathectomy is described. A successful result was obtained in I4 cases (52%) at 6 months falling to I2 (45%7o) at i6 months. Prediction of outcome and postoperative progress was monitored by the measurement of the leg: arm pressure ratio using the Doppler ultrasound apparatus. No patient with a preoperative ratio of less than 0.3 had a successful result. It is proposed that lumbar sympathectomy is a logical adjunct to surgery in these patients in order to enhance the development of the collateral circulation. Introduction The use of profundoplasty as an alternative to femoropopliteal bypass for the relief of intermittent claudication of the lower limb is now well known" 2. Recently it has been shown that extending the angioplasty as far down the profunda trunk as possible (extended deep femoral angioplasty (EDFA)) may improve the results3. There is also some evidence that the addition of lumbar sympathectomy may be beneficial4. We were therefore interested to determine how effective the combined operations of EDFA and lumbar sympathectomy would be as a limb salvage procedure in patients who were suffering from severe rest pain, limited digital gangrene, and/or ischaemic ulceration for whom arterial reconstruction was the only alternative to major amputation. Materials and methods The operation was performed on 27 limbs (26 patients, i 8 male and 9 female). Age at operation ranged from 48 to 84 years with a
mean of 66.5 years. All patients had severe rest pain, I5 digital gangrene, i o ischaemic ulceration, and 2 both ulceration and gangrene. Before operation translumbar or percutaneous femoral angiography was performled to determine whether or not the run-in to the common femoral artery was adequate and also to assess the degree of run-off as shown by the patency and number of vessels seen below the knee. In addition, a preoperative assessment of the pedal perfusion pressure was made by measuring the leg:arm pressure ratio with the Doppler ultrasound apparatus (Model 802, Park Electronic). The technique used was similar to that described by Yao et al5. In the postoperative period the pressure ratios were measured at intervals in order to determine the correlation between these numerical values and the clinical success or failure of the arterial reconstruction. The result was judged to be successful if relief of rest pain was complete and ischaemic ulcers or digital amputation wounds healed, partially successful if there was a temporary improvement, and a failure if there was no change.
Operative technique The operation is performed through a long vertical groin incision, very much as described by Cotton and Roberts3. The deep femoral artery is extensively mobilised from its origin as far down its course as possible; this varied from 4 to I7 cm (mean 8.5 cm) in this series before healthy artery suitable for the distal anastomosis was reached. After incision a suitable piece of woven Dacron is fashioned
*Fellows and Members interested in submitting articles for consideration with a view to publication in this series should first write to the Editor.
Extended deep femoral angioplasty and lumbar sympathectomy
147
performed for digital gangrene in 5 cases, one of which required split skin grafting. All healed uneventfully. Included in this group were the 4 patients in whom a femoropopliteal bypass was possible, emphasising that run-off was better in this group. The mean preoperative pedal perfusion ratio was o.68 and in all cases there was a significant rise in the postoperative period to a mean of o.8s. Two patients were diabetic. Follow-up to February I978 has been from io months to 25 months with a mean of I5.7 months. Two patients have come to below-knee amputation at Io months and i8 months respectively, one from progressive disease and one with angiographically proven occlusion of the profunda trunk. PARTIALLY SUCCES SFUL
EDFA at conclusion of operation, showing woven Dacron patch extending from common femoral bifurcation for a distance of IO cm down the profunda trunk. and sutured into place as a patch (see figure) and the skin closed with suction drainage. A lumbar sympathectomy is then performed through a standard muscle-splitting incision. We prefer to perform any minor forefoot amputation at this stage rather than delay for two or three weeks as recommended by some'. As advocated by Cotton and Roberts we also omit the endarterectomy, which makes the operation easier and shorter and lessens the risk of distal intimal flap dissection. In only 4 cases would femoropopliteal bypass have been technically possible as an alternative procedure and in one case extensive distal disease made even the performance of EDFA impossible. Results SUCCESSFUL
Seven limbs (26%) showed a temporary improvement, with reduction in rest pain, but complete relief did not occur and 5 patients have since come to amputation, although a below-knee operation was satisfactory in 3 of these. This group of patients had a lower mean preoperative pedal perfusion ratio (o.s6) and the rise in the postoperative period (mean o.62) was also lower than in the successful group. One of these patients was diabetic; relief of his rest pain was sufficient for him to keep his limb until he relapsed at 6 months, when angiography confirmed a blocked deep femoral trunk. FAILURES
Six limbs (2 2 go) showed no improvement and all came to early above-knee amputation. The mean preoperative pedal perfusion pressure ratio was low (0.36) and in no case was there a rise after the operation. This group included the one patient in whom extensive distal disease of the profunda femoris precluded operation. Two patients were diabetic; in one of these the artery thrombosed in the early postoperative period and despite re-exploration patency could not be restored, necessitating high above-knee amputation.
Discussion
The outcome was successful in 14 limbs The elderly patient with chronic lower limb (527C) at 6 months and I2 limbs (45Co) ischaemia presents an increasingly common at I6 months. Local amputation was problem today. There is no doubt that the
I48
I M Stevenson, P N Wake, and G J Santer
results of major amputation are poor and that these patients impose heavy burdens on the ancillary services of the National Health Service7. While claims have been made for successful local amputation with pedal perfusion pressures as low as 35 mm Hg (4.7 kPa)8, this is not a general experience and in any case does not relieve the main symptom of rest pain. There are significant numbers of these patients with disease primarily below the inguinal ligament who are not suitable for femoropopliteal bypass or similar operations. In addition, although disease in the deep femoral artery is often more marked at its origin, it is now recognised that extensive disease may be present without arteriographic signs9. This has been our experience, and in 8 cases (29 7o) it has been necessary to mobilise the artery for over io cm before healthy artery has been reached. Since the aim of deep femoral angioplasty is to increase the blood flow into the collateral circulation, the performance of lumbar sympathectomy as an adjunct to surgery is logical since it has been shown to enhance the development of the collateral circulation10. It is this group of patients who, we believe, are best served by EDFA and lumbar sympathectomy as a means of limb salvage. In previous series attempts to predict the outcome of the operation have been made on the basis of inspection of the distal run-off on the arteriograms. In our experience this, although helpful, is not without inaccuracy and we feel we have had more success in predicting the outcome of operation by using the leg: arm pressure ratio as a measure of
pedal perfusion pressure. No patient with a preoperative ratio of 0.3 or below had a successful result-a total of 5 cases (i8%) in the series-and we would now regard it as unjustifiable to attempt operation in this group of patients. There was no operative mortality in the series, but 8 patients (27%7o) have since died, 4 from coronarv occlusion, 2 from coexistent malignant disease, and 2 from unknown causes. This serves to emphasise that these patients are elderly, with generalised arterial disease, and may also have other disabilities. Salvage of a pain-free limb may make the difference between a mobile and bedridden existence. We are grateful to Mr Paul Atkins and Mr John Littler for allowing us to oiperate on their patients.
References I
2
3
4 5 6
7 8 9 io
Martin, P, Frawley, J, Barabas, A, and Rosengarten, D (1972) Surgery, 71, I82. Martin, P, and Bouhoutsos, J (I977) British Journal of Surgery, 64, I94. Cotton, L T, and Roberts, V C (1975) British Journal of Surgery, 62, 340. Morris-Jcnes, W, and Jones, C D P (I974) American Journal of Surgery, I72, 68o. Yao, S T, Hobbs, J T, and Irvine, W T (i96o) British Journal of Surgery, 56, 676. Yogasundram, Y N (1976) British Journal of Surgery, 63, 37I. Harris, P L, Read, F, Eardley, A, Charlesworth, D, Wakefield, J, and Sellwood, R A, (I974) British Journal of Surgery, 6i, 665. Verta, M J jr, Gross, W S, Van Bellen, B, Yao, S T, and Bergen, J J (1976) Surgery, 80, 729. Buerger, R, Cotton, L T, and Sabri, S (I973) British Medical Journal, 2, 469. Sheperd, J T (1950) Clinical Science, 9, 49.
