COMMENTARY

Prosthetic Bypass Surgery Can Salvage Lower Limbs

Frank J. Veith, MD

Disclosures

November 16, 2015

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Editor's Note:
The value of prosthetic bypass surgery for lower limbs threatened by gangrene and ulceration will be one of the issues discussed at the upcoming VEITHsymposium, to be held November 17-21 in New York City. As a preview, Dr Frank Veith provides his views on the challenges, risks, and benefits associated with this surgery.

I am Frank Veith, professor of surgery at New York University and the Cleveland Clinic. Today I am going to talk about a controversial topic—namely, the value of prosthetic or polytetrafluoroethylene (PTFE) bypasses to tibial and peroneal arteries in the leg.

Saving lower extremities that are threatened by gangrene or ulceration because of occluded lower-limb arteries is now possible in most instances. These so-called limb salvage procedures, designed to improve circulation to the foot, have recently been greatly improved by the development of better devices and techniques—mainly smaller angioplasty balloons—for opening small blocked arteries in the leg and foot.[1,2,3]

The small leg arteries are known as crural arteries, which consist of the anterior and posterior tibial arteries and the peroneal artery. Blockage of these leg arteries exists in a large percentage of patients with a limb endangered because of poor circulation.[4]

Although endovascular treatments can reopen most of these blocked crural arteries, in some patents the arteries will reocclude, and other patients have arteries that are not suitable for such treatment. A surgical bypass is then required.[5] Although the patient's own saphenous vein is the best conduit for such a bypass, many patients with a threatened limb do not have a suitable saphenous vein.[4,5]

The patient then faces the option of a major lower-extremity amputation or attempting to save the limb with a PTFE bypass to his or her patent crural artery beyond its blockage. Such bypasses have been highly controversial for the past three decades. Many surgeons have been unable to get good outcomes with them, whereas others have and believe them worthwhile.[6,7,8,9]

 
The salvage of such limbs can persist in more than 70% of surviving patients for 3 years
 

Those surgeons who advocate PTFE crural bypasses believe they can save the limbs of some patients who otherwise face immediate amputation. Moreover, the salvage of such limbs can persist in more than 70% of surviving patients for 3 years and more than 50% of surviving patients for 5 years.[5,8,9] However, it is important to recognize that there are three considerations:

1. Many of these patients require a redo or revision of their bypass.

2. Some patients do not have recurrence of their gangrene when their bypass occludes.

3. The life expectancy of patients undergoing these PTFE crural bypasses is often less than 5 years.

Although there may be many technical issues, requirements, and qualifications, the important bottom line is that PTFE bypasses to crural arteries can be worthwhile and save limbs for important periods of time in some patients who are otherwise facing a major amputation.

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