A STUDY TO DETERMINE THE SHORT TERM OUTCOME OF INFRAINGUINAL BYPASS FOR CRITICAL LIMB ISCHEMIA
Authors:   Senior Resident Department of Cardiovascular and Thoracic Surgery Government Medical College kottayam, former Junior Resident, Department of General Surgery Amala Institute of Medical Sciences and Research Institute Thrissur., Joseph Jose Jeevan , Rizwan T. Mohamed ,   Assistant Professor Department of General Surgery Amala Institute of Medical Sciences and Research Institute Thrissur., Kumar Marar Krishna ,   Professor and HOD Department of General Surgery Amala Institute of Medical Sciences and Research Institute Thrissur., Anto C. Rajesh ,   Vascular Surgeon and Assistant Professor Department of General Surgery , Amala Institute of Medical Sciences and Research Institute Thrissur.
Published: December 2024

Introduction: Critical limb ischemia is defined as persistent, recurring ischemic rest pain requiring opiate analgesia for at least 2 weeks, or ulceration or gangrene of the foot or toes and ankle systolic pressure lower than 50 mm Hg or toe systolic pressure lower than 30 mm Hg. CLI is a clinical diagnosis and it should be confirmed early and objectively through ABI, toe systolic pressure or transcutaneous partial pressure of oxygen (TcPO2). Once the diagnosis is confirmed, the goals of treating CLI are to relieve ischemic pain, heal ischemic ulcers, prevent limb loss, improve patient function and QOL and prolong survival. Revascularization will help to achieve these goals. The aim of the study is to assess the outcome of infra-inguinal bypass surgery in all PVD patients who presented to our General Surgery department with CLI.

Objectives: To assess the following in CLI after infra-inguinal bypass surgery: 1) Wound healing 2) Limb salvage 3) Self assessed degree of ambulation 4) Primary patency of graft-using arterial doppler

Methods: This is a single directional cohort study conducted in 48 patients who presented to Amala General Surgery Department with critical limb ischemia, who underwent infra-inguinal bypass surgery with reversed saphenous vein graft. PVD patients with CLI were assessed preoperatively. Periodic assessment was also done during postoperative period at 1 month and 6 months. Primary graft patency was checked at 6 months using arterial doppler. These patients were monitored closely during the pre-operative period, during surgery and postoperative period. They were also followed up at 1 and 6 months. The study duration is 18 months, from January 2018 to June 2019.

Results and Discussion: From January 2018 to June 2019, 48 patients (37 males, mean age of 65 years) underwent infrainguinal bypasses (37 femoropopliteal, 11 femorodistal) for CLI (12 Fontaine III and 36 Fontaine IV).There was no perioperative mortality. The mean duration of hospitalization was 10.542 with standard deviation of 3.2809.Wound healing observed at 1 month is 39.58%, which was increased to 77.08 % at the end of 6 months (Mc Nemar Test p value=0.0001).Limb salvage attained at the end of 6 months is 87.5%.Ambulatory status of the patients were assessed at the end of 1 month after surgery and only 2% were ambulatory outdoors, 90 % were ambulating indoors and 8% were non-ambulatory. Total ambulatory status post-surgery (indoor and outdoor combined), came around 92% at 1 month. At 6 months post-surgery, 19 % of patients were ambulating outdoors, 60 % were ambulating indoors and 21 % were non-ambulatory. Total ambulatory status at 6 months (indoor and outdoor combined) post-surgery came around 79 % (Mc Nemar Test p value = 0.001) and primary patency of the graft at 6 months for our cohort is 79.2%.

Conclusion: This Study includes 48 patients with CLI who has undergone infrainginal bypass with reversed saphenous vein graft. 87.5% limb salvage, 77.08% wound healing at 6 months, 79% was ambulatory status at 6 months and 79.2% primary graft patency were attained.. 7 out of 8 CLI patients treated surgically has limb salvage and good functional status.