Sequential by-passes for limb salvage.

Direct revascularisation of the foot permits the healing of distal trophic lesions. This is not always possible with a by-pass on a single isolated popliteal segment. When multi-segmental occlusive arterial lesions were found in femoral, popliteal and distal arteries sequential by-pass grafting was used to improve distal runoff. During a 5 year period (1988-1992), 53 sequential by-passes were performed in 52 patients with severe ischemia manifested by rest pain (17) or trophic lesions (36). Autogenous saphenous vein was used in 36 (10 reversed, 26 in-situ), homologous saphenous in 3 and composite (PTFE+saphenous) in 14. Proximal anastomosis was performed on 29 common femoral, 20 superficial femoral and 4 popliteal arteries. Intermediary anastomosis was performed on 6 above-knee and 31 below-knee popliteal arteries and on 16 distal arteries. All distal anastomoses were performed on distal arteries (13 cases on malleolar arteries). The mean follow-up was 18 months. Thirteen patients died during this period (mean 8.5 months after the surgery). Primary and secondary patency were respectively 66 and 79% over one year and 51 and 76% over two years. Limb salvage was obtained in 89% over one year and 86% over 2 years. Sequential by-pass is a useful alternative for limb salvage. This approach offers several hemodynamic advantages and may be the best procedure in patients with poor distal runoff.