Surgical management of critical limb ischaemia in the French West Indies

This retrospective study analyses the clinical presentation, surgical management and early outcome of 174 patients (mean age +/- SEM: 73 +/- 15 yrs) admitted for critical limb ischaemia. 145 (84) had tissue loss at admission: toe gangrene or ischaemic ulcer in 77, and gangrene extending beyond the forefoot in 68. 87 primary limb amputations and 107 revascularisations were performed at iliofemoral (n = 20), suprapopliteal (n = 22) or infrapopliteal level. The postoperative mortality rate was 14in the [quot ]Amputation[quot ] group and 9in the [quot ]Revascularisation[quot ] group but the difference was not statistically significant. Infective complications were comparable in both groups, although 5 of 14 deaths after amputation were directly related to infection and all deaths after revascularisation resulted from cardiovascular complications. The early limb salvage rate after revascularisation was 82. 19 secondary limb amputations were performed for bypass failure. Patients in whom primary amputations were required were older (p < 0.03) and had significantly higher rates of heart disease and nonambulatory status (respectively, 24 vs 17, p < 0.05; and 37 vs 13, p < 0.001) than patients in whom revascularisation was performed. Ischaemic rest pain and tissue loss confined to digit gangrene or ischaemic ulcer occurred more frequently than extensive gangrene in the [quot ]Revascularisation[quot ] group (p < 0.0001), while extensive gangrene extending beyond the forefoot occurred more frequently than ischaemic rest pain and tissue loss in the [quot ]Amputation[quot ] group (p < 0.0001). Late presentation of patients and enhanced tissue loss are probably the reasons for the higher primary amputation rate in our patients compared to that observed elsewhere. In patients amenable to revascularisation (56), arterial reconstruction for critical limb ischaemia improves the chances of limb salvage.

Infrapopliteal bypass for critical limb Ischaemia: early experience in the French West Indies

From December 1992 to October 1995, 42 infrapopliteal arterial bypass operations for limb salvage were performed in 39 patients (including 22 diabetics) with limb ischaemia (mean age, 71 years). Thirty-four patients (87 percent) had tissue loss at admission (8 ulcers, 13 digit gangrenes and 13 extensive foot infections). Angiographic findings were consistent with artherosclerotic involvement of femroal and crural arteries. Outflow anastomic sites were the popliteal (n = 5); tibial (n = 14); peroneal (n = 14) and pedal artery (n = 9). Autogenous saphenous vein was suitable in 27 procedures and inadequate in 15 (<3 mm diameter, with gross fibrosis or segmental occlusion) requiring prosthetic or composite grafts. Postoperative mortality rate was 10 percent, related to concomitant cardiovascular diseases. Mean follow-up was 14 months (range, 3 - 35). Fourteen bypasses failed, 5 in the early period (8 - 30 days) and 9 within a mean interval of 7.6 months, resulting in 6 limb amputations. Overall life-table primary graft patency rates were 72 percent (ñ 8) at 12 months and 61 percent (ñ 9) at 2 years and were not significantly different in diabetic patients compared to those in non-diabetics. Primary graft patency rates were significantly lower in prosthetic or composite grafts compared to saphenous vein grafts (75 percent vs 32 percent at 2 years - p<0.01), respectively. Overall life-table limb salvage rates were 84 percent (ñ 7) and 76 percent (ñ 9) at 12 and 24 months respectively. Seventy-eight percent of patients with limb salvage were relieved of ischaemic symptoms, 57 percent regained the ability to ambulate with improved functional level and 85 percent of tissue loss healed within a mean interval of 55 days. Infrapopliteal bypass operations for critical limb ischaemia performed in Martinique provide a fair chance of limb salvage despite limitations of medical facilities.