General Considerations

Considerable attention has been given to improving the long-term results of peripheral grafting, mainly emphasizing proper patient selection and refinement of surgi cal technique. Several factors, such as patient characteristics, smoking, graft placement, surgical experience and adjunctive medications, have been investigated as to whether they affect the results of femorodistal by-passes [17, 24, 43, 52, 67, 74, 75]. Although certain diseases, such as renal failure and diabetes, have implications for peri-operative morbidity and long-term survival, none has any predictive value for graft patency [39, 45, 61, 94]. The only reliable predictors of graft patency are derived from the anatomical and haemodynamic aspects of the reconstruction itself, such as the quality and origin of the conduit and its outflow bed.

There are, however, some critical issues that are decisive for the successful outcome of femorodistal reconstructions. The first is the arteriographic technique, with which all patent, named arteries in the leg and foot should be visualized. Only with accurate imaging of the extent of occlusive and stenotic disease can revascularization of distal arteries be planned appropriately. Of even greater importance is the fact that the limb-salvage surgeon should have appropriate training, experience and a meticulous and fine technique. Surgical manipulations (occlusion, arteriotomy and suturing) must be performed with diligence, since many patients have extensive atheromatous involvement or heavy calcification in the patent segment of the artery available for anastomosis. Moreover, the skilled surgeon should be familiar with all surgical options that are available. Finally, it has to be made clear that disadvantaged outflow arteries such as those connecting incomplete plantar arches, those consisting of isolated or blind segments, and those with considerable disease or heavy calcification can sometimes serve as effective sites for by-pass implantation. This high operability is further increased by the use of appropriate measures preopera-tively, intraoperatively and postoperatively to accomplish with reasonable safety the sometimes long operation designed to save a limb. From this point of view, careful preoperative cardiac evaluation with a resting ECG and a transthoracic echocardiography is crucial since cardiac disease is the main source of morbidity and mortality in these operations.

Last but not least, vein mapping, using ultrasound imaging, is considered to be an essential step in the completion of the preoperative evaluation of patients. Identification of usable autologous grafts facilitates operative plans and prevents unnecessary exploration, which has the potential to cause wound complications [77].

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