Highlights

Preventable amputations

September 23, 2015

Foot vascular surgery to prevent amputations

Occasionally, medical situations that lead the patient to the possibility of losing a limb are presented. In this article, Dr. Such explains how the chance of saving them in certain circumstances exists. In that way, the doctor Miguel Such, cardiovascular surgeon, exposes that “the cholesterol setting in arteries, called ‘atherosclerosis’, is the main cause of blood irrigation disorders. Any artery of the body could be affected, but this illness is located more frequently in heart and legs. In the first case, ‘coronaries’ are damaged, which are then ones that irrigate the heart and allow it to contract without ceasing and with the necessary strength. The seriousness of the problems that they cause is clear and, because of this, the efforts on their treatment and prevention are maximum. However, the obstruction of the legs’ arteries doesn’t receive such attention, although it is the main cause of amputations in our country.”

The doctor wants to tackle “the options of treatment in its last phase, when the amputation is imminent. The best option for recovering the blood irrigation in legs is the execution of what we call a ‘by-pass’, a difficult word to translate, although we may call it a ‘branch’ or a ‘bridge’. It implies connecting a ‘tube’, that can be a vein or a synthetic pipe, to the principal artery and before the obstruction that is causing the problem. The opposite end is connected to a healthy section, past the lesion, with what the blood returns to flow as before, recovering the irrigation. Thus, we achieve that a high number of persons return to have a normal mobility when, in spite of medication, they were disabled. But atherosclerosis is a progressive illness, and many times are getting affected more extended areas from the legs’ arteries, making impossible to find a healthy part to connect the distal end of the bypass. In this cases, the surgery does not have opportunities, and the lack of irrigation provokes increasing pain and, finally, the gangrene, which leads to the amputation.

Ten years ago, they started a program in order to try “to save those legs from amputation” (already described in English as ‘limb salvage’). The first step consist in identifying any section more or less healthy in any different artery from those which are normally used for the bypasses, as the ones which are placed around the foot. For this, “we have to do what we call a ‘selective arteriography’, which consists in taking contrast to these areas that generally aren’t studied since the blood, and consequently the contrast, takes a lot and arrives to them with difficulty, due to precisely the generalised obstructions. In those cases in which was impossible to sight any vase, we used the ultrasound technique, the ‘Doppler’, to locate any section with flow. Henceforth, we design a specific surgery for each patient”, Such affirms.

The key to succeed is “having a ‘vein’ from the patient, since the synthetic pipes would be obstructed quickly. Secondly, is finding the shortest way to carry blood to the foot, considering that length influences in the results”.

As well, the Dr. adds that “we believe that is important that the surgeon have experience in coronary surgeries, since the size of the arteries and the sutures needed is similar as the used in the heart, and the bypass technique has to be exactly the same as the one we use for the coronaries. There also has to be used the magnifying glasses (which are regular in the coronary surgeries and allow until 4.5 increases) which permit the necessary precision in every point, provided that any imperfection limiting the blood flow could cause the surgery failure”.

“All patients came with the ‘terminal ischemia’ diagnosis and all of them were waiting for amputation. Only in two cases the foot skin was intact. The others presented diverse degrees of gangrene, with or without additional infection. All of them were informed about the complexity of the surgery and the foreseeable percentage of success”.

“Each of the surgeries performed during these years has been absolutely different from the others. In some cases, we have been able to do it just before the ankle. For the other ones, it was necessary to operate the foot directly. We obtained a usable section of vein in the same leg of the bypass in every patient except from one, who came with all his veins useless because of the multiple surgeries previously performed, with what we used the saphenous vein from the other leg, the ‘healthy’ one. In several occasions we had to modify the initial plan due to the impossibility of sewing up the artery provided that the calcium was taking up the inside vase almost entirely, but always being able to find another point nearby for the bypass”.

Once the blood flow was restored, it was necessary to ‘clean’ widely the gangrene zone in patients with additional infection, whom were more than a half”.

Results

With the provided results, Dr. Such certifies that “the percentage of ‘saved legs’ was less than a 70%. In two cases, the bypass stopped functioning before the patient was discharged and was necessary to amputate during the same hospitalization. In the other ‘failures’, the gangrene was such advanced that, despite a good blood flow, the infection continued advancing, risking the patients’ life, which made the subsequent amputation unavoidable.

But the most important, and even surprising for us, is that all the patients discharged with a functioning bypass and the skin lesions healed, have preserved their leg. Some of them have passed away due to other issues (most of them have an advanced age), but each one of them preserved their bypass with a correct flow despite the atherosclerosis progress. We think that the blood pressure in very tiny arteries helps to maintain always open an exit, an essential condition for its functioning.

The principle on which this ‘in extremis’ surgery is based has been known since much time, and it’s called the ‘Bypass to Isolated Artery Section’. It lies in taking the flow to an artery with blood (with contrast in the study) but obstructed in both ends. The fact of having contrast means that the blood enters in and leaves from it through extremely tiny vases which, although we not see them, we know that are there and that they are the ones which spread out the ‘new’ blood that arrives through the bypass. We have confirmed that this also works with the smalls arteries of the foot, and that it’s maintained along the years with the help of ‘anticoagulants’ (Sintrom, which prevents the appearance of clots) and ‘antiplatelet’ (which prevents from obstructions caused by platelets). But the evidence is that, after ten years, we have saved a significant number of legs that already were beforehand headed for amputation, with results that have been maintained during the years and even beyond our own previous expectations. Therefore, all patients who are going to be amputated should be studied again, searching the possibility of applying this technique which could avoid the leg loss.”