The results of tibial artery reconstruction procedures

Less than 30% of patients who present with an imminent loss of the lower extremity due to occlusive arterial disease distal to the superficial femoral arteries have one or more patent arteries below the knee suitable for arterial reconstruction. Precise preoperative angiographic delineation of these vessels can be achieved with the aid of ischemic reactive hyperemia induced during the angiographic study, using multiple injections of contrast medium and multiple films by changers. Arterial reconstruction is possible approximately to midcalf level by medially placed incisions, occasionally with a lateral incision to expose the midanterior tibial artery. More distal involvement requires reconstruction to the level of the tibial malleoli. Angiographic criteria for selection of patiens for operation are reliable. A complete pedal arch is required for successful malleolar bypass. A patent anterior or posterior tibial artery from midcalf distally is needed for below knee reconstructions. The peroneal artery is an unreliable outflow tract. Below knee reconstructions appear to have greater durability than malleolar reconstructions if performed by the criteria outlined. Late failures of arterial reconstruction may be associated with maintenance of an improved clinical state, especially in diabetics with traumatic infectious gangrene in the presence of arterial occlusions. Early failures are due to inadequate outflow tracts or technical errors. Late failures are due to intimal or neointimal fibroplasia whose mechanism of occurrence is not as yet understood, appears to be hemodynamically dependent on, but no related to the initial outflow tract.