Bypass surgery or percutaneous transluminal angioplasty to treat critical lower limb ischaemia due to infrainguinal arterial occlusive disease?

OBJECTIVES: To define the role of bypass surgery and percutaneous transluminal angioplasty to manage critical limb ischaemia due to infrainguinal arterial occlusive disease. DESIGN: Retrospective review. SETTING: Regional hospital, Hong Kong. PATIENTS: Consecutive patients treated for critical limb ischaemia, for whom data were prospectively collected in those who underwent: (i) infrainguinal percutaneous transluminal angioplasty first, or (ii) infrainguinal bypass surgery. RESULTS: Among patients with critical lower limb ischaemia, 364 consecutive individuals having infrainguinal bypass operations and 100 having percutaneous transluminal angioplasty first were compared. The latter patients were older (77 vs 74 years, P=0.014) and had more co-morbidities but higher ankle pressure than those having bypass surgery. In the angioplasty-first group, 74% had favourable lesions (classified as TransAtlantic Inter-Society Consensus A/B). In the bypass group, operative mortality was higher (4% vs 1%, P=0.03) than that in the angioplasty-first group. Hospital mortality was comparable (8% vs 3%, P=0.15). In the bypass group, median hospital stay was longer than that in the angioplasty-first group (24 vs 4 days, P<0.001), and postoperatively they also had a higher median ankle-brachial index (0.92 vs 0.70, P<0.001) and superior long-term patency. In the bypass group, American Society of Anesthesiologists class 4 patients suffered very high operative and hospital mortality (15% and 31%, respectively). Long-term patency of percutaneous transluminal angioplasty depended on the TransAtlantic Inter-Society Consensus class of the treated lesion. Limb salvage rates at 3 years were 89% and 78% for percutaneous transluminal angioplasty first and surgical bypass, respectively (P=0.046). Long-term survival was poorer in the percutaneous transluminal angioplasty-first group (21% vs 51% at 5 years, P=0.04). CONCLUSION: Infrainguinal bypass and percutaneous transluminal angioplasty are complementary. For TransAtlantic Inter-Society Consensus A and B lesions, percutaneous transluminal angioplasty should be offered first. For American Society of Anesthesiologists class 4 patients, percutaneous transluminal angioplasty should be considered first, regardless of the TransAtlantic Inter-Society Consensus class.

Arterial reconstruction for lower limb ischaemia in Hong Kong Chinese.

BACKGROUND: Lower limb ischaemia due to peripheral arterial disease is uncommon in Chinese people, and few arterial bypass operations have been performed. The management of a consecutive series of patients who were admitted to our department with severe lower limb ischaemis between March 1990 and October 1996 is reported here. METHODS: A total of 91 primary arterial bypass operations were performed for 83 patients (eight patients had bilateral, or two procedures). Of these, 84 operations were for foot salvage and seven operations were for debilitating claudication. There were 80 infra-inguinal bypasses, 10 of which required additional femoro-femoral crossover grafts to improve in-flow. The remaining 11 bypass procedures were performed for aorto-iliac occlusion, which included aortobifemoral bypass (5), axillobifemoral bypass (3) and cross-femoral bypass (3) grafts. There were 46 male and 37 female patients, with a median age of 70 years (36-94). RESULTS: Six patients died (6.6%) postoperatively, all of whom were in the foot salvage group. The overall cumulative foot salvage rate and graft patency was 84 and 56%, respectively, at 5 years. CONCLUSIONS: These results justified the use of the same aggressive approach that was adopted in Western countries for the treatment of peripheral arterial disease, which seemed to be an emerging problem in Hong Kong.

Comparison of a single layer continuous hand-sewn method and circular stapling in 580 oesophageal anastomoses.

A total of 611 patients with carcinoma of the oesophagus or gastric cardia were operated on between July 1982 and December 1989. Resection was performed in 491 patients (one-stage, 483; two-stage, eight), bypass operation in 97, and 23 had exploration alone. The anastomoses of 580 patients with one-stage resection and bypass operations were evaluated. Hand-sewn anastomosis using a single layer of continuous absorbable monofilament suture was performed in 304 patients (221 resections and 83 bypasses). A stapled anastomosis was performed on 276 patients (262 resections and 14 bypasses). Following resection, there were 11 (5 per cent) anastomotic leaks in the hand-sewn group and ten (3.8 per cent) in the stapled anastomosis group (P = 0.69). Excluding anastomotic leaks, hospital mortality and anastomotic recurrence, stricture occurred in 18 of 172 hand-sewn anastomoses (10.5 per cent) and in 57 of 195 stapled anastomoses (29.2 per cent) (P less than 0.001). In patients who had bypass operations there were 12 anastomotic leaks, ten in the hand-sewn group (12.0 per cent) and two in the stapled anastomosis group (14.3 per cent). Only two of the discharged patients with bypass developed anastomotic strictures, a low incidence probably because of short survival. In addition, there were 245 subsidiary anastomoses made in the abdomen by the hand-sewn method as part of the reconstructive procedure, and there was one leak. The results of this non-randomized study suggest that hand-sewn anastomosis using a single layer continuous technique for the oesophagus is as safe as the use of circular staplers; hand-sewn anastomosis is less likely to become stenotic.