Limb salvage by inverted "Y" grafts to below knee arteries.

(1) An inverted Y graft to the proximal tibial arteries is described, and the limited clinical experience with this type of graft is presented. (2) The inverted Y graft provides a low-resistance high-low situation, which theoretically favors graft patency. (3) This clinical series confirms the value of bypass procedures to small, below-knee arteries in limb salvage situations. An excellent rate of success can be accomplished if meticulous surgical technique is used to implement the principles of small vessel surgery.

Retroperitoneal aortofemoral bypass using a reversed L-shaped prosthesis.

An extraperitoneal approach for aortofemoral bypass has proven superior to the transperitoneal approach. The incision starts at the tip of the eleventh rib and extends obliquely downward to 2 inches above the femoral point, where it turns further downward over the femoral artery. This approach is especially suitable for a reversed L-shaped prosthesis which extends from the aorta directly to the left femoral artery and crosses the abdomen subcutaneously to the right groin, where an anastomosis is made with the right femoral artery. The operation is simple and rapid. Morbidity is reduced and recovery is accelerated. The same incision is used to perform aortoiliac endarterectomy. Fifteen patients with occlusive disease and twenty-one with aneurysms received reversed L-shaped prosthesis through an extraperitoneal approach. The procedure was superior to that involving a transperitoneal approach to the aorta and the reversed L-shaped graft was superior to the Y graft for replacement fo the iliac arteries.

Limb salvage by inverted Y vein grafts to below-knee arteries.

Distal Y branches to other below-knee arteries were added to standard femorotibial bypass grafts to increase runoff, more effectively perfuse the ischemic limb, and improve limb salvage rate. Y grafts were performed in 16 lower limbs in 15 patients. Flow through the graft was increased significantly with each additional Y limb. Preoperative angiograms demonstrated filling of the distal vessels. Surgical indications were gangrenous toes or ischemic ulcers in 12 patients, and 13 limbs were saved. Three patients received bypass grafts for acute ischemic changes, limbs were salvaged in two of the three patients. Two Y grafts performed in 1971 and in 1974 remain patent. Between 1971 and 1977, forty standard femorotibial bypasses were done, with a long-term patency rate of 54%. During the past two years, 13 more Y grafts were performed, with an overall initial patency of 94%. Late results of the Y grafts have been surprisingly good, with no subsequent loss of grafts or limbs.