LIMB SALVAGE IN CRITICAL LIMB ISCHAEMIA IN THROMBOANGIITIS OBLITERANS PATIENTSREVASCULARISATION- A STUDY
Journal Title: Journal of Evolution of Medical and Dental Sciences - Year 2018, Vol 7, Issue 33
Abstract
BACKGROUND Buerger’s disease, pathologically named Thromboangiitis Obliterans (TAO) has for long remained a disease difficult to understand due to the various theories ascribed to its pathogenesis and lack of consensus regarding accurate diagnostic criteria. A significant proportion of our patients in our population present with characteristic features of TAO, except that they have occlusive disease in the medium and larger sized arteries including the femoral and iliac arteries. This study attempts to present our principles guiding revascularisation in critical limb ischaemia patients with TAO and analyse the surgical outcomes in terms of graft patency, ulcer healing and limb salvage. MATERIALS AND METHODS This is a retrospective observational study. All patients admitted with the clinical diagnosis of TAO from August 2011 to December 2013 (retrospective study) were included and their case sheets were analysed. Salient features were then recorded from these case records including age, clinical presentation and management strategies employed. Patients underwent conservative management, primary amputation or plan for revascularisation. Shionoya criteria were used for the classification of the disease. RESULTS The total no. of revascularisation procedures done were 60. In the planned 60 patients, surgical revascularisation could be accomplished in only 50 patients, while in 10 patients the planned bypass had to be abandoned in view of either poor distal outflow or lack of quality vein. In the operated group of patients, five patients underwent iliofemoral bypass with synthetic graft. Twentyfive patients underwent femoro-popliteal bypass, while twenty patients underwent tibial bypass with autologous vein graft. All patients were operated under regional anaesthesia. Average duration of surgery ranged between 3 - 4 hours. All patients received anticoagulation. Surgical revascularisation resulted in relief of rest pain in thirty six out of the sixty patients in the immediate postoperative period. The average period of hospitalisation was seven days postoperatively. There was no postoperative mortality. At 6 months of follow-up, thirty-two patients showed successful results in terms of surgical outcome with twenty patients having a palpable pulse and twelve patients showed ABI improvement. This recorded a primary graft patency rate of 64%. The thirty-six limbs salvaged recorded a limb salvage rate of 80%. Major amputation was necessitated in nine patients with an amputation rate of 20%. Minor amputation was done on all the salvaged limbs, which included great toe disarticulation in seven patients, other toe disarticulation in nine patients and forefoot amputation was needed in twenty patients (80%). Post revascularisation complications included major infection (n= 1) with graft infection resulting in pseudoaneurysm of the distal anastomosis of the anterior tibial artery despite a successful bypass and a below knee amputation was needed in one patient. Other complications included minor bleeding (n= 2), minor wound infections (n= 9) which were treated conservatively. CONCLUSION TAO continues to be a significant source of limb loss and morbidity. The mean age of all TAO patients with CLI was 35 years. Most patients presented with critical limb ischaemia. Angiographically, majority had femoropoliteal segment occlusion. Suprageniculate disease affects a significant proportion of patients with TAO in our population. All patients with suprageniculate disease have infrageniculate disease as well. Primary amputation was needed in 30% patients with TAO. Revascularisation could be attempted in 10 - 15% patients with TAO. Suprapopliteal vessel disease is more amenable for revascularisation with the possibility of a suitable distal vessel unlike infrapopliteal disease, where suitable distal vessels for revascularisation are often absent. Pathogenic mechanisms for initiation and progression of disease at different levels in the arterial tree are different. The different pathogenic and anatomic factors impact the probability of revascularisation and limb salvage.
Authors and Affiliations
Maruthu Thurai Sambandam, Velladuraichi Boologapandian, Amalorpavanathan Joseph
Keywords
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- EP ID EP541864
- DOI 10.14260/jemds/2018/826
- Views 84
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