Patient recovery after infrainguinal bypass grafting for limb salvage

Abstract

PURPOSE The outcome of infrainguinal bypass surgery for limb salvage has traditionally been assessed by graft patency rates, limb salvage rates, and patient survival rates. Recently, functional outcome of limb salvage surgery has been assessed by patient ambulatory status and independent living status. These assessments fail to consider the adverse long-term patient effects of delayed wound healing, episodes of recurrent ischemia, and need for repeat operations. An ideal result of infrainguinal bypass surgery for limb salvage includes an uncomplicated operation, elimination of ischemia, prompt wound healing, and rapid return to premorbid functional status without recurrence or repeat surgery. The present study was performed to determine how often this ideal result is actually achieved. METHODS The records of 112 consecutive patients who underwent initial infrainguinal bypass surgery for limb salvage 5 to 7 years before the study were reviewed for operative complications, graft patency, limb salvage, survival, patient functional status, time to achieve wound healing, need for repeat operations, and recurrence of ischemia. RESULTS The mean patient age was 66 years. The mean postoperative follow-up was 42 months (range, 0 to 100.1 months). After operation 99 patients (88%) lived independently at home and 103 (92%) were ambulatory. There were seven perioperative deaths (6.3%), and wound complications occurred in 27 patients (24%). By life table, the assisted primary graft patency and limb salvage rates of the index extremity 5 years after operation were 77% and 87%, respectively, and the patient survival rate was 49%. At last follow-up or death, 73% of the patients (72 of 99) who lived independently at home before the operation were still living independently at home, and 70% (72 of 103) of those who were ambulatory before the operation remained ambulatory. Wound (operative and ischemic) healing required a mean of 4.2 months (range, 0.4 to 48 months), and 25 patients (22%) had not achieved complete wound healing at the time of last follow-up or death. Repeat operations to maintain graft patency, treat wound complications, or treat recurrent or contralateral ischemia were required in 61 patients (54%; mean, 1.6 reoperations/patient), and 26 patients (23.2%) ultimately required major limb amputation of the index or contralateral extremity. Only 16 of 112 patients (14.3%) achieved the ideal surgical result of an uncomplicated operation with long-term symptom relief, maintenance of functional status, and no recurrence or repeat operations. CONCLUSIONS Most patients who undergo infrainguinal bypass surgery for limb salvage require ongoing treatment and have persistent or recurrent symptoms until their death. A significant minority have major tissue loss despite successful initial surgery. Clinically important palliation is frequently achieved by bypass surgery, but ideal results are distinctly infrequent.