Pedicled flaps in association with distal bypass for lower-limb salvage.

BACKGROUND: After distal bypass for limb salvage, persistence of large ischemic ulcers with exposure of tendons, joints, and bone and secondary graft exposure can lead to amputation, even though the bypass remains patent. Coverage of such defects using free flaps is too lengthy and complex for use in elderly patients. Although quick and simple, pedicled flaps are often considered to be contraindicated in patients with occlusive artery disease. The purpose of this study was to evaluate the outcome of pedicled flaps harvested after evaluation of revascularized territories on angiograms for coverage of tissue defects. METHODS: From 1994 to 2000, a total of 23 pedicled flap procedures were performed in 22 patients with a mean age of 75 years (range, 54-91 years). The distal anastomosis of the bypass was located on a tibial or pedal artery in 19 cases and on the popliteal artery in 4. The indication for flap placement was chronic ulcer in 7 cases, secondary graft exposure in 15, and open fracture with acute ischemia in 1. To be considered as usable, the flap had to be vascularized by a pedicle fed by the bypassed artery and have a rotational axis sufficient to cover the defect. Muscle flaps were used in 11 cases, fasciocutaneous flaps in 10, and fascial flaps in 2. RESULTS: The flap procedures in this study led to primary healing in 17 cases, secondary healing in 4 cases, and failure due to necrosis in 2. Follow-up examination was carried out with Doppler ultrasonography at 1, 6, and 12 months and every 6 months thereafter. The mean follow-up period was 23 months (range, 3-5 years). Statistical analysis demonstrated bypass patency, limb salvage, and survival rates in agreement with those previously reported in the literature. CONCLUSIONS: Our results suggest that pedicle flaps are feasible after distal bypass in patients with lower-extremity occlusive artery disease. This technique expands the indication for limb salvage with low morbidity.

Management of perianastomotic stenosis of direct wrist autogenous radial-cephalic arteriovenous accesses for dialysis.

OBJECTIVE: Radial-cephalic fistulas (RCFs) perianastomotic stenoses (PASs) are on and around the fistula anastomosis. This group of lesions encompasses juxta-anastomotic stenosis (stenosis located on the venous side within 3 cm away from the anastomosis), anastomotic, and arterial stenosis. The purpose of our study was to assess the postintervention primary patency and assisted postintervention primary patency (APP) rates for surgery and angioplasty when treating these stenoses. The secondary endpoint was to identify factors that might influence the procedure's patency rates. MATERIALS AND METHODS: This retrospective study included 73 consecutive patients treated for lack of maturation PASs between January 1999 and December 2005 in two interventional centers. Patients' mean age was 65 years old. Stenoses were treated by surgery (n = 21) or percutaneous transluminal angioplasty (PTA; n = 52). Surgery meant creation of a new anastomosis excluding the area of stenosis. Preoperative characteristics including the patient's age, gender, comorbidities, stenosis location, and length were not statistically different between the two groups. The mean follow-up was 39 months for PTA and 49 months for surgery. RESULTS: Anatomical and clinical success rates were 86% and 90% for surgery, and 75% and 92% for PTA. At 1 year, the primary patency rates were 71 ± 10% for surgery and 41 ± 6% for PTA, respectively (P < .02). There was no significant difference between the two groups with respect to assisted primary patency (95% vs 92%). In the PTA group, stenosis location at the anastomosis itself was a risk factor of early recurrence (P = .047). The complication rate was similar between surgery and PTA. CONCLUSION: Our results suggest that the treatment of anastomotic stenoses should be surgical rather than endovascular. Angioplasty and surgery have shown similar results when used to treat other perianastomotic stenoses, but repeat procedures were more frequent with angioplasty.