Scot. med. J., 1976, 21: 194
RECONSTRUCTIVE SURGERY IN GANGRENE J. O'Connor, W. Reid, J. K. Watt and J. G. Pollock Peripheral Vascular Unit, Royal Infirmary, and Belvidere and Stobhill Hospitals, Glasgow
Summary. The results of reconstructive arterial surgery in 113 critically ischaemic limbs during 1958 to 1972 are presented. There were 61 aorto-iliac reconstructions with 4 operative deaths (6.5%), resulting in a limb salvage rate of 75.4 per cent and 49 femoro-popliteal operations with 3 deaths (6.1 %) and a limb salvage rate of 73.5 per cent.
W
the viability of a leg is threatened by ischaemia, reconstructive arterial surgery may restore sufficient circulation to avert gangrene and subsequent amputation. In the attempt to save a limb, greater operative risks are acceptable than in surgery for the relief of intermittent claudication (Watt, 1974), but the operative risk of reconstructive surgery for the relief of gangrene is often no greater than the risk of amputation (Dale, 1962). Material and results All of the patients in this series presented with or developed symptoms and signs heralding amputation of a leg i.e. persistent ischaemic rest pain, painful ulceration, necrosis of toe or established gangrene (Morris, 1962). Almost every patient presenting in this way had had a previous lumbar sympathetic block with 1 :15 phenol (Reid, 1970), and those who achieved viability by this simple technique are not included in this series. During the period 1958-72, 113 operations were performed in 104 patients. There were 85 males and 19 females (a male/female ratio of 4.5/1) and the mean age at operation was 56 years (range 23-83 years). At operation on 3 occasions, reconstruction was not possible, the procedure was abandoned and amputation was performed. Nine patients had 2 reconstructive operations because of new vascular incidents involving the same or opposite limb. In the 101 patients undergoing reconstruction, there were 7 operative deaths (6.9%): due to coronary artery thrombosis (2); cerebro-vascular disease (1); cardiac failure (1); broncho-pneumonia (2); and HEN
haemorrhage from the anastomsis due to infection involving the graft (1). Thirty one patients died between operation and followup, leaving 63 patients available for review. Sixty one (96.8%) were examined personally, the remaining 2 patients living too far away to travel and an assessment of their current status was obtained from their medical practitioner. There were 61 aorto-iliac reconstructions (Table I) with 4 operative deaths-a mortality rate of 6.5 per cent. Eleven reconstructions failed and amputation was required, giving an immediate salvage rate, on dismissal from hospital of 75.4 per cent. There were 49 femoro-popliteal operations (Table II), with 3 operative deaths - a mortality rate of 6.1 per cent. Ten patients required amputation before leaving hospital and the immediate salvage rate was therefore 73.5 per cent. In the 36 bypass vein grafts, the lower anastomosis was above the level of the knee joint in 16 and below knee joint level in 20, but there was no significant difference in salvage rates related to the level of distal anastomosis. In the whole series, therefore, there were 3 cases in which reconstruction was not possible; 7 patients died as a result of operation, 21 required amputation in spite ot attempted reconstruction, and 82 operations (72.6%) were successful at the time the patient left hospital. Eighteen legs subsequently deteriorated and required late amputation, the mean time interval from discharge to amputation being 9 months. There was no significant difference in the late amputation rate between aorto-iliac and femoro-popliteal reconstruction.
Reconstructive Surgery in Gangrene
Table I. Immediate salvage and amputation rates in aortic-iliac reconstruction. --
--
-----
--~
Operative procedure Bifurcation graft Unilateral graft Endarterectomy Total
- - - - - - - - - , - - _..
Number 25 23 13 61
--~
Deaths 4 0 0 4
11
Salvage % 68.0 78.3 84.6 75.4
Salvage % 73.0
Amputation 4 5 2
Table II. Immediate salvage and amputation rates in femoro-popliteal reconstruction. Operative procedure By-pass graft (36 Vein, 1 Dacron) Endarterectomy Profundaplasty Total
Number 37
Deaths 2
Amputation 8
9 3 49
1 0 3
1 1 10
77.8 66.6 73.5
In 27 cases, reconstruction was successful fore, there is a mean between excessive zeal but the graft subsequently thrombosed with- and undue caution, and the aim is to achieve out loss of limb, a paradox well known in the as high a salvage rate as possible with as low a mortality as possible. In our own practice, treatment of these patients (Taylor, 1971). there is no doubt that a large proportion of Discussion patients achieve viability after the simple Although the mortality rate of operation procedure of phenol block (Reid, 1970) and found in this series (6.7%) is higher than that only those who continue to complain of reported in our claudication series (Watt, persistent pain and necrosis are recom1974), it is far from prohibitive and compares mended for reconstructive surgery. favourably with the mortality rate for In many patients the degree of circulatory amputation alone (Dale, 1962). Even in our improvement required to avert amputation 10 patients aged 70 years and over, of whom is marginal and, consequently, temporary one died, the risk has been acceptable. Naturally, the mortality rate varies according improvement in collateral flow may be to the criteria adopted for the selection of sufficient to establish absolute improvement. This is the explanation for the well known patients, and it is sometimes better to accept paradox of graft failure and limb survival amputation than to embark on a futile (Taylor, 1971) which was seen in 19 of our reconstruction and secondary amputation. patients after discharge from hospital. In the In our own patients, it is routine to under8 patients who had a successful reconstructake angiography before deciding to proceed tion but whose grafts failed without loss of to amputation. Only in the very unfit or in limb before dismissal, there are grounds for those where necrosis has extended to involve the foot or leg is angiography omitted. Where wondering whether such a short period of function contributed to limb survival, or an operable occlusion has been demonwhether these few might have achieved strated, reconstructive surgery is attempted. viability without operation. Early experience of arterial reconstrucIt is surprising that there was relatively tion, whereby Roberts (1958) quoted a salvage rate of 20 per cent was not encourag- little variation in salvage rates between aortoing but later reports of larger series quoted iliac and femoro-popliteal surgery and little primary salvage rates of 80 per cent (Morris, difference between the various types of 1962), 72 per cent (Harrison, 1964), and procedure. Our own preference is for bypass 78.7 per cent (Taylor, 1971). There is no surgery although Taylor (1964) found a higher doubt that the salvage rate depends to a large success rate with thrombo-endarterectomy. The long term limb survival rate of 65 per extent on the selection of lesions and patients. In both mortality and salvage rates, there- cent found in this series is similar to that 195
O'Connor, Reid, Watt and Pollock
found in other series embracing a variety of surgical procedures (Taylor, 1971; Stefanics, 1972) and there is no doubt that reconstructive surgery can avert gangrene with demonstrable immediate and long term benefit to these patients. REFERENCES Dale, W. A., Jacobs, J. K. (1962). Lower extremity amputation: results in Nashville 1956-60. Annals of Surgery, 155, 1011 Harrison, J. E., Preez, A. R. (1964). Advanced ischaemia. Archives of Surgery, 89, 817 Morris, G. c., Wheeler, C. G., Crawford, E. S., Cooley, D. A., De Bakey, M. E. (1962). Restorative vascular surgery in the presence of impending and overt gangrene of the extremities. Surgery, 51, 50
196
Reid, W., Watt, J. K., Gray, T. G. (1970). Phenol injection of the sympathetic chain. British Journal of Surgery, 57, 45 Roberts, B., Hoffman, D. (1958). Arterial grafting in severely ischaemic legs. Journal of the American Medical Association, 166, 1316 Stefanics, J., Jambor, Gy., Csengody, J., Nagy, L. (1972). Reconstructive arterial surgery for major gangrene of the lower limb. Vascular Surgery, 6, 133 Taylor, G. W. (1964). Arterial surgery for major gangrene. Journal of Cardiovascular Surgery,S, 523 Taylor, G. W. (1971). Limb salvage arterial surgery for gangrene. Postgraduate Medical Journal, 47, 251 Watt, J. K., Gillespie, G., Pollock, J. G., Reid, W. (1974). Arterial surgery in intermittent claudication. British Medical Journal, 1, 23
RECONSTRUCTIVE SURGERY IN GANGRENE J. O'Connor, W. Reid, J. K. Watt and J. G. Pollock Peripheral Vascular Unit, Royal Infirmary, and Belvidere and Stobhill Hospitals, Glasgow
Summary. The results of reconstructive arterial surgery in 113 critically ischaemic limbs during 1958 to 1972 are presented. There were 61 aorto-iliac reconstructions with 4 operative deaths (6.5%), resulting in a limb salvage rate of 75.4 per cent and 49 femoro-popliteal operations with 3 deaths (6.1 %) and a limb salvage rate of 73.5 per cent.
W
the viability of a leg is threatened by ischaemia, reconstructive arterial surgery may restore sufficient circulation to avert gangrene and subsequent amputation. In the attempt to save a limb, greater operative risks are acceptable than in surgery for the relief of intermittent claudication (Watt, 1974), but the operative risk of reconstructive surgery for the relief of gangrene is often no greater than the risk of amputation (Dale, 1962). Material and results All of the patients in this series presented with or developed symptoms and signs heralding amputation of a leg i.e. persistent ischaemic rest pain, painful ulceration, necrosis of toe or established gangrene (Morris, 1962). Almost every patient presenting in this way had had a previous lumbar sympathetic block with 1 :15 phenol (Reid, 1970), and those who achieved viability by this simple technique are not included in this series. During the period 1958-72, 113 operations were performed in 104 patients. There were 85 males and 19 females (a male/female ratio of 4.5/1) and the mean age at operation was 56 years (range 23-83 years). At operation on 3 occasions, reconstruction was not possible, the procedure was abandoned and amputation was performed. Nine patients had 2 reconstructive operations because of new vascular incidents involving the same or opposite limb. In the 101 patients undergoing reconstruction, there were 7 operative deaths (6.9%): due to coronary artery thrombosis (2); cerebro-vascular disease (1); cardiac failure (1); broncho-pneumonia (2); and HEN
haemorrhage from the anastomsis due to infection involving the graft (1). Thirty one patients died between operation and followup, leaving 63 patients available for review. Sixty one (96.8%) were examined personally, the remaining 2 patients living too far away to travel and an assessment of their current status was obtained from their medical practitioner. There were 61 aorto-iliac reconstructions (Table I) with 4 operative deaths-a mortality rate of 6.5 per cent. Eleven reconstructions failed and amputation was required, giving an immediate salvage rate, on dismissal from hospital of 75.4 per cent. There were 49 femoro-popliteal operations (Table II), with 3 operative deaths - a mortality rate of 6.1 per cent. Ten patients required amputation before leaving hospital and the immediate salvage rate was therefore 73.5 per cent. In the 36 bypass vein grafts, the lower anastomosis was above the level of the knee joint in 16 and below knee joint level in 20, but there was no significant difference in salvage rates related to the level of distal anastomosis. In the whole series, therefore, there were 3 cases in which reconstruction was not possible; 7 patients died as a result of operation, 21 required amputation in spite ot attempted reconstruction, and 82 operations (72.6%) were successful at the time the patient left hospital. Eighteen legs subsequently deteriorated and required late amputation, the mean time interval from discharge to amputation being 9 months. There was no significant difference in the late amputation rate between aorto-iliac and femoro-popliteal reconstruction.
Reconstructive Surgery in Gangrene
Table I. Immediate salvage and amputation rates in aortic-iliac reconstruction. --
--
-----
--~
Operative procedure Bifurcation graft Unilateral graft Endarterectomy Total
- - - - - - - - - , - - _..
Number 25 23 13 61
--~
Deaths 4 0 0 4
11
Salvage % 68.0 78.3 84.6 75.4
Salvage % 73.0
Amputation 4 5 2
Table II. Immediate salvage and amputation rates in femoro-popliteal reconstruction. Operative procedure By-pass graft (36 Vein, 1 Dacron) Endarterectomy Profundaplasty Total
Number 37
Deaths 2
Amputation 8
9 3 49
1 0 3
1 1 10
77.8 66.6 73.5
In 27 cases, reconstruction was successful fore, there is a mean between excessive zeal but the graft subsequently thrombosed with- and undue caution, and the aim is to achieve out loss of limb, a paradox well known in the as high a salvage rate as possible with as low a mortality as possible. In our own practice, treatment of these patients (Taylor, 1971). there is no doubt that a large proportion of Discussion patients achieve viability after the simple Although the mortality rate of operation procedure of phenol block (Reid, 1970) and found in this series (6.7%) is higher than that only those who continue to complain of reported in our claudication series (Watt, persistent pain and necrosis are recom1974), it is far from prohibitive and compares mended for reconstructive surgery. favourably with the mortality rate for In many patients the degree of circulatory amputation alone (Dale, 1962). Even in our improvement required to avert amputation 10 patients aged 70 years and over, of whom is marginal and, consequently, temporary one died, the risk has been acceptable. Naturally, the mortality rate varies according improvement in collateral flow may be to the criteria adopted for the selection of sufficient to establish absolute improvement. This is the explanation for the well known patients, and it is sometimes better to accept paradox of graft failure and limb survival amputation than to embark on a futile (Taylor, 1971) which was seen in 19 of our reconstruction and secondary amputation. patients after discharge from hospital. In the In our own patients, it is routine to under8 patients who had a successful reconstructake angiography before deciding to proceed tion but whose grafts failed without loss of to amputation. Only in the very unfit or in limb before dismissal, there are grounds for those where necrosis has extended to involve the foot or leg is angiography omitted. Where wondering whether such a short period of function contributed to limb survival, or an operable occlusion has been demonwhether these few might have achieved strated, reconstructive surgery is attempted. viability without operation. Early experience of arterial reconstrucIt is surprising that there was relatively tion, whereby Roberts (1958) quoted a salvage rate of 20 per cent was not encourag- little variation in salvage rates between aortoing but later reports of larger series quoted iliac and femoro-popliteal surgery and little primary salvage rates of 80 per cent (Morris, difference between the various types of 1962), 72 per cent (Harrison, 1964), and procedure. Our own preference is for bypass 78.7 per cent (Taylor, 1971). There is no surgery although Taylor (1964) found a higher doubt that the salvage rate depends to a large success rate with thrombo-endarterectomy. The long term limb survival rate of 65 per extent on the selection of lesions and patients. In both mortality and salvage rates, there- cent found in this series is similar to that 195
O'Connor, Reid, Watt and Pollock
found in other series embracing a variety of surgical procedures (Taylor, 1971; Stefanics, 1972) and there is no doubt that reconstructive surgery can avert gangrene with demonstrable immediate and long term benefit to these patients. REFERENCES Dale, W. A., Jacobs, J. K. (1962). Lower extremity amputation: results in Nashville 1956-60. Annals of Surgery, 155, 1011 Harrison, J. E., Preez, A. R. (1964). Advanced ischaemia. Archives of Surgery, 89, 817 Morris, G. c., Wheeler, C. G., Crawford, E. S., Cooley, D. A., De Bakey, M. E. (1962). Restorative vascular surgery in the presence of impending and overt gangrene of the extremities. Surgery, 51, 50
196
Reid, W., Watt, J. K., Gray, T. G. (1970). Phenol injection of the sympathetic chain. British Journal of Surgery, 57, 45 Roberts, B., Hoffman, D. (1958). Arterial grafting in severely ischaemic legs. Journal of the American Medical Association, 166, 1316 Stefanics, J., Jambor, Gy., Csengody, J., Nagy, L. (1972). Reconstructive arterial surgery for major gangrene of the lower limb. Vascular Surgery, 6, 133 Taylor, G. W. (1964). Arterial surgery for major gangrene. Journal of Cardiovascular Surgery,S, 523 Taylor, G. W. (1971). Limb salvage arterial surgery for gangrene. Postgraduate Medical Journal, 47, 251 Watt, J. K., Gillespie, G., Pollock, J. G., Reid, W. (1974). Arterial surgery in intermittent claudication. British Medical Journal, 1, 23
