REINTERVENTION AFTER VASCULAR-SURGERY FOR CRITICAL LEG ISCHEMIA

Re-operation after arterial bypass in the leg is common, may be seen as failure by many and can appear expensive to budget holders. Secondary reconstruction may wt be undertaken for these reasons. The indications for and outcome of further intervention have been studied in 395 primary presentations with critical leg ischaemia, all of whom underwent arterial reconstruction. During the study period the primary amputation rate was 3%, and 10% of reconstructed patients presented with skin necrosis or gangrene. One hundred and twenty-nine reconstructions (32 %) were to crural vessels in the lower third of the calf. Mean follow-up was 3 years, 1 month mortality was 2 % and overall mortality 20%. One hundred and seventy-three (44%) patients required further intervention: 118 (30%) for recurrence of ipsilateral ischaemic symptoms and 55 (14%) in the presence of a patent primary graft (mostly operations on the contralateral leg). A total of 695 secondary operations were required over follow-up, a mean 1.75 additional operations per patient per 3 years. Following recurrence of ischaemia, graft revision or secondary revascularisation was undertaken in 98 of 118 (84%) legs whilst the remaining 19 legs had an amputation performed after primary graft failure. Secondary reconstruction was successful in salvaging 63 limbs to mean follow-up, a 64% success rate from revisional surgery. At mean follow-up 339 of 395 limbs remain viable (86% limb salvage), secondary graft patency is 79% and primary graft patency 63%. Failure to re-intervene after primary graft failure would reduce limb salvage at 3 years to 70% with corresponding loss of 63 legs. As the value of femoro-crural reconstruction in limb salvage is disputed by some, we have performed a similar analysis of our cohort of 129 reconstructions to crural vessels. Eighty-seven of these patients (67%) required further operations: 63 (48%) for recurrence of ipsilateral critical ischaemia and 24 (19%) in the presence of a patent primary graft (mostly operations on the opposite leg). A total of 253 secondary operations were required in this group over follow up, a mean 2.0 operations per patient per 3 years. Graft revision or further reconstruction after recurrence of ischaemic symptoms was performed in 50 of 63 legs, whilst early amputation was required in the remaining 13. Secondary reconstruction was successful in salvaging 22 legs, a 44% success rate for revisional surgery. Following femoro-crural reconstruction, 88 limbs remained viable to follow-up, a 3-year limb salvage of 68%. Secondary graft patency is 67% and primary patency 47%. Failure to re-intervene after primary graft failure would reduce limb salvage at 3 years to 51% with corresponding loss of 22 legs. Aggressive arterial reconstruction, to all levels in the leg, combined with follow-up and re-intervention, can salvage 86% of critical legs to intermediate follow-up. Limb salvage is 68% when femore-crural reconstructions alone are considered. Secondary vascular reconstruction is successful in 64% of legs with recurrence of ischaemic symptoms and 44% of femoro-crural reconstructions in which recurrence occurs. Re-intervention should therefore be considered an integral part of an aggressive reconstruction policy, even in the most distal grafts.