Revascularization is the first step in the treatment for limb salvage of critical limb ischemia complicated by ulceration and/or necrosis. General foot care, including rehabilitation and the use of a footwear, is later essential for wound care and recovery of walking function. We investigated the method of bypass surgery and subsequent wound care, especially the influence of the level of amputation on walking function in 100 Fontaine class IV limbs of 93 patients who underwent bypass surgery after 2003. Bypass surgery was performed above the knee (AK-FP) in 28 limbs, below the knee (BK-FP) in 20 limbs, and on the tibioperoneal area (Ti-P) in 52 limbs. Two-year primary/secondary patency rates of AK-FP, BK-FP, and Ti-P were 85.2/93.7%, 73.8/73.8%, and 71.8/78.3%, respectively, and the limb salvage rate was 90.3/85.0% for Year 1/ Year 5, which was favorable. However, survival rates were as low as 85.0/56.6%. After bypass surgery, 39 limbs had no minor amputations, 31 limbs required stump plasty of the toes, and 1 limb required debridement of the heel. No patients had reduction of post-operative walking function. Amputation at the metatarsal level was performed on 20 limbs, and 15 of 17 patients who had been able to walk before surgery retained their walking ability at the time of discharge (the walking function retention rate was 88.2%). No patients with Chopart disarticulation (1 limb), below-knee amputation (5 limbs), and above-knee amputation (3 limbs) were able to walk after surgery. Patients with critical limb ischemia often have a poor prognosis, even if limb salvage is possible. We therefore consider that it is important to retain walking function by revascularization and subsequent wound care.
An 84-year-old woman with acute left limb ischemia was admitted to our hospital. Three-dimensional computed tomography confirmed a left popliteal artery aneurysm (PAA) and occlusion of the PAA. To prevent limb amputation, prompt percutaneous aspiration thrombectomy (PAT) and pharmacologic catheter-directed thrombolysis (CDT) were needed. The initial treatment was successful. Therefore, this patient was electively treated with expanded PTFE graft interposition with resection of the PAA. The postoperative course was uneventful and she was discharged on the ninth day after the operation.