SPECIAL ARTICLE

Practice guidelines: Lower extremity revascularization

James A. DeWeese, MD, Robert Leather, MD, and John Porter, MD, Rochester and

Albany, N.Y., and Portland, Ore.

Currently in the United States about 100,000 operative surgical procedures, and probably an equal number of interventional radiologic procedures, are performed annually for revascularization of ischemic lower extremities. 1 The need for the majority of these procedures results from symptoms caused by atherosclerosis. The purpose of this document is to present practice guidelines for lower extremity revascularization. It is obvious that guidelines can be neither comprehensive nor exclusive. Deviations from these guidelines can and should occur when warranted by patient circumstances. The subjects addressed include indications for revascularization taking into account the natural history of untreated lower extremity ischemia, pretreatment evaluation, methods for treatment, care and monitoring during treatment, and posttreatment follow-up.

INDICATIONS FOR LOWER EXTREMITY R E V A S C U L A R I Z A T I O N 2,s Patients requiring lower extremity revascularization have one or more well-recognized symptom complexes. In addition to symptoms, the decision to proceed with treatment is dependent on the presence of appropriate physical findings, noninvasive testing results, and lesions demonstrated by imaging techniques, as well as a knowledge of the natural history of the patient before surgery.
From the Division of Cardiothoracic and Vascular Surgery, University of Rochester Medical Center (Dr. DeWeese), Rochester; the Department of Surgery,AlbanyMedicalCollege (Dr. Leather), Albany; and the Division of Vascular Surgery, University of Oregon Medical School (Dr. Porter), Portland. Reprint requests: James A. DeWeese,MD, Division of Cardiothoracic and Vascular Surgery,Universityof RochesterMedical Center, 601 ElmwoodAve., Rochester, NY 14642. J VAsc SUING 1993;18:280-94. Copyright 1993 by The Societyfor Vascular Surgery and International Societyfor CardiovascularSurgery,North American Chapter. 0741-5214/93/$1.00 + .10 24/9/47174

Symptoms Chronic ischemia Claudication. Clandication consists of weakness, discomfort, or muscular cramping occurring only with exercise and relieved by a short period of rest. Symptoms typically occur in muscle groups distal {~ the site of arterial occlusion and may involve the buttock, thigh, or calf. The pain is caused by failure of lower extremity blood flow to increase sufficiently to meet the metabolic demands of exercising muscle, although the pain receptor pathways are unknown. Restpain. Rest pain consists of a constant aching discomfort or burning pain typically occurring in the forefoot. It worsens with elevation, is lessened by dependency, and is most troublesome at night. This pain is caused by diminished blood flow that is inadequate to meet the metabolic demands of resting tissue. Ischemic ulceration. Failure of minor traumatic lesions to heal normally leads to painful chronic ulcers that fail to heal because of reduced blood supply insufficient to meet the increased demands of healing tissue. Ischemic ulcers also typically occur in the distal extremity. Gangrene. Gangrene is characterized by cyanotic, anesthetic tissue associated with, or progressing <'~:, necrosis as a result of reduction of arterial blood supply below that necessary to meet minimal metabolic requirements. Acute ischemia Blue toe syndrome. The blue toe syndrome consists of sudden onset of painful cyanosis of the toes or forefoot in the presence of pedal pulses resulting from embolic occlusion of digkal arteries with atherothrombotic material from proximal arterial sources. 4 Dij~se acute ischemia. Acute diffuse limb ischemia is characterized by the sudden onset of pain progress~ ing to numbness and finally paralysis of the extremity, accompanied by pallor, coolness, and absence of

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palpable pulses. Acute ischemia is typically caused by embolic or thrombotic occlusions of native arteries or previous vascular reconstruction.

Physical findings associated with lower extremity ischemia

Diminished pulses. Most patients with symptomatic lower extremity ischemia have diminished or absent pulses at one or more levels in the symptomatic extremity. Patients with palpable pulses that disappear with exercise may also have proximal arterial occlusJive disease. 5 Other physical findings. Other signs of chronic ischemia have been described including presence of hair loss, thickened nails, cyanosis, rubor, coolness, pallor, delayed capillary filling, muscular wasting, and a positive elevation dependency test. The elevation dependency test consists of elevation of both legs 30 ~egrees from the horizontal position for 30 seconds and then return of the legs to the horizontal position. Capillary filling and pinkness will return progressively from the heel to the forefoot and finally the great toe. Capillary filling and venous filling will normally occur within 10 seconds. With the exception of the elevation dependency test, all of these signs are sufficiently nonspecific or influenced by environmental conditions (i.e., temperature) to be of little practical use. Noninvasive testing 2,3 Physical examination alone is unreliable for complete assessment of lower extremity ischemia. Deterruination of palpable pulse status is not reproducible :and should not be relied on to assess the presence or severity ofischemia. Objective noninvasive testing is ~readily available and reliable and should be a part of l~e preoperative evaluation of all patients with lower extremity ischemia. The available modalities and ~lications are listed below. Anlde/bractfial systolic arterial pressures (ABIs). The highest arterial pressure measured at the ~alkle with an ultrasonic flow detector divided by the highest arm blood pressure gives the ABI. The severity of occlusive disease in the lower extremity is inversely related to the ABI, as is the severity of symptoms. 6 Resting ABIs of patients considered for therapy are generally 0.5 or less in patients with incapacitating intermittent claudication, 0.3 or less in patients with ischemic rest pain, and 0.4 or less in patients with gangrene or tissue loss. This simple measurement should be performed as part of the physical examination of all persons suspected of

having lower extremity ischemia. In urgent or emergent cases, or in occasional patients with typical symptoms and findings, no other tests may be necessary. Unfortunately the index may- be falsely elevated in patients with incompressible lower extremity arteries as occurs in diabetes.

Segmental pressures and Doppler analog waveform recording. Segmental pressures and
Doppler analog waveform recording are most helpful in localizing the site of obstructive lesions. They are usually performed at the upper thigh, lower thigh, calf, and ankle. Doppler waveforms are also obtained from the femoral artery for evaluation of inflow. Exercise testing. Treadmill walking with pretreatment and postexercise ankle blood pressure provides objective confirmation of the diagnosis of claudication and allows objective comparison of pretreatment and posttreatment values for the assessment of results. Pulse volume recordings. The pulse volume recording is a calibrated air plethysmographic waveform recording system test that is performed at thigh, calf, ankle, metatarsal, mad toe levels. It provides semiquantitative information of arterial obstruction. Toe pulse volume recordings and toe pressures are especially helpful in diabetic patients with relatively incompressible proximal vessels preventing accurate pressure measurements. Duplex scanning. Duplex examinations of the lower extremity arteries and bypass grafts may localize and quantitate lesions, differentiate stenoses from occlusions, and measure flow velocities in bypass grafts.

Imaging examinations
Invasive therapy of lower extremity atherosclerosis is based on the segmental nature of the responsible lesions. Precise localization of lesions to permit procedural planning is presently possible only through detailed arteriography. In most cases the arteriograms should include the aorta, lilac, femoral, popliteal, and tibia/arteries of one or both legs. The pullback pressure gradient determination during induced reduction in outflow resistance provides important information on the hemodynmnic significance of iliac lesions. Well-described angiographic techniques permit visualization of all vessels that remain patent even in severely ischemic extremities. 7 It should rarely be necessary to perform elective arterial surgery for ischemia without precise arteriographic definition of lesions. In the future detailed duplex examinations and magnetic resonance imag-

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ing may provide sufficient detail to replace arteriography, but not currently. Natural history and indications The natural history of untreated lower extremity ischemia forms the foundation on which all decisions for treatment are based. Chronic lower extremity ischemia. Lower extremity arterial ischemia is a result of stenosis or occlusion of the aortoiliac or femoropopliteal or tibioperoneal arteries. The occlusion is most frequently the result of atherosclerotic plaque with or without secondary thrombosis. However, it may also result from emboli, thrombosis of aneurysms, popliteal entrapment, fibrodysplasia, adventitial cystic disease, spontaneous arterial dissection, arteritis, radiation, trauma, or Buerger's disease. Claudieation. Numerous reports have described the generally benign nature ofclandication indicating the infrequency of disease progression to amputation. 8,9 Although the impression that patients with claudication have a benign natural history with respect to limb loss is widespread, it is probably incorrect. The "classic" studies that predate the use of modern methods of objective noninvasive vascular diagnosis (and in fact usually depended on questionnaires) are flawed by inclusion of an unknown but significant number of patients whose leg pain with walking was not vascular. The effect is to assign an incorrectly benign prognosis to the entire patient group. Modern studies of claudicants in which objective documentation of arterial disease was required for study entry have clearly shown that the prognosis for limb loss is related most closely to the severity of disease at the time of study entry, as assessed by ankle pressure measurements or other means. The need for amputation or therapy to prevent amputation occurs annually in 4% to 8% of claudicants followed prospectively.9-12 Diabetes mellitus adversely affects the 5-year outcome of the claudicant and increases the amputation rate as much as sevenfold.9 Clinical deterioration with either requirement for bypass or tissue loss occurred in 35% of those with and 19% of those without diabetes mellitus. Smoking also adversely affects the 5-year outcome of patients with claudication. 9 Worsening of claudication occurred in 31% of patients who continued smoking compared with 8% of those who stopped. For claudicants who continued smoking, major amputations have been required in 11% of cases, compared with 0% for those who stopped.

The amputation rate is most closely related to severity of arterial disease as determined by ankle pressure or arteriography at the time of presentation with claudication.9,n14 Humphries et al)0 have shown that sudden severe ischemia occurs in only 11% of claudicants with isolated aortoiliac occlusion within 4.2 years (average) of onset of symptoms but was more than twice as likely to occur in patients with femoropopliteal or multisegmental disease. The natural history of claudication argues against arterial reconstruction for all patients with intermittent claudication. Most claudicants do not have limb-threatening ischemia during 5 years of follow-up. Cessation of smoking can improve symptoms and decrease the risk of deterioration. It has also been shown objectively that a walking exercise program can increase the comfortable walking distance. 1~ On the other hand, the observation that approximate~ 25% of patients do have deterioration within 5 years emphasizes the importance of objective follow-up, preferably with noninvasive testing. This is particularly true of patients with diabetes and continued smoking, because these patients have a four to seven times greater risk of deterioration. A well-planned elective operation for the deteriorating extremity is preferable to an urgent or emergent operation on an acutely ischemic limb. In addition, there is a variable but small number of patients with sufficiently severe claudication that they are prevented from performing tasks required for their livelihood or desired recreational activity. In these instances a revascularization procedure may be offered to an informed patient who does not have. unduly significant risk factors or other extenuating circumstances. For example, if the patient requires a bypass to the tibial level and has no available saphenous vein, the long-term results of a nonvein bypass do not justify intervention for patients with only claudication. Rest pain, ischemic ulcers, and gangrene. Imminent or actual tissue loss, particularly in the presence of pain, is the most frequent indication for lower extremity arterial reconstruction. Despite risk factors, these patients are generally facing surgery of one type I or another: arterial reconstruction or amputation. Blue toe syndrome. 4 Digital arterial occlusion may result from in situ thrombosis from many causes such as atherosclerosis, collagen-vascular arteritis, and Buerger's disease. Alternatively, it may result from embolization from a proximal cardiac or arterial~ source, such as a ventricular thrombus, aortic aneurysm, or ulcerated stenotic upstream arterial plaque.

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Management: of the source of the embolus, if extracardiac, is usually indicated. Acute lower extremity ischemia. The natural history of acute lower extremity ischemia is variable, ranging from rapid spontaneous improvement to progression to tissue death. Factors favoring a benign prognosis include presence of preexisting collaterals (i.e., preexisting history of clandication or previous arterial reconstruction), presence of audible arterial flow by Doppler at the time of presentation, and absence of neurologic changes at the time of presentation (sensation and normal movement intact). Factors predicting a more morbid prognosis include absence of preexisting arterial disease (as in embolic or traumatic arterial occlusions), absence of detectable Doppler signals, presence ofneurologic changes, and presence of muscular rigidity. In addition to an uncertain natural history with respect to the threat~ned limb, acute lower extremity ischemia is associated with significant mortality rates (a mean mortality rate of approximately 25% in the series reviewed by Blalsdell et al. 16Death was attributable to both the systemic effects of severe limb ischemia (myonecrosis, acute renal failure, and multiple organ system failure) and the serious nature of underlying disease in persons suffering acute limb ischemia (e.g., severe heart disease, advanced malignancy, and multiple trauma).16 It is important that limb-revascularization procedures be: performed early and expeditiously in the face of deteriorating clinical findings and be withheld in the face of irreversible ischemic changes. Asymptomatic disease Abdominal aortic aneurysms. The presence of an aneurysm 4 cm in diameter or greater in the presence of symptomatic aortoiliac occlusive disease is an indication for aneurysm resection if there are no other overwhelming medical problems. 17 Peripheral arterial aneurysms. The complications f peripheral arterial aneurysms including thrombosis, embolization, rupture, and compression of adjacent structures are sufficiently frequent to justify their repair when discovered. Neoplasms. Limb-sparing surgery for treatment of bulky extremity rumors may involve resection of critical arteries and veins, necessitating revascularization. PREOPERATIVE GENERAL EVALUATION Virtually all studies of patients with symptomatic lower extremkT atherosclerosis have reported decreased life expectancy compared with symptom-free age-matched control subjects. The causes of death are

most frequently related to atherosclerosis at other sites, with myocardial infarction, stroke,and other vascular events (e.g., ruptured aneurysm and visceral ischemia) accounting for more than three fourths of the deaths. 3 The risk of death appears to be related directly to the severity of lower extremity ischemia, whether assessed by objective means or severity of symptoms. For example, the mortality rate at 5 years of follow-up was 13% in a series of patients with claudication treated nonoperatively~8 and 20% in a series of claudicants requiring surgery, 19 but it was 52% in a series of patients requiring surgery for limb salvage2 and 88% in a group of patients who underwent repeat operations for limb salvage. 21 These studies and others indicate that the Severity of the process of systemic atherosclerosis is reflected accurately in the severity of lower extremity occlusive disease as determined by objective testing. Identification of the extent of the systemic arteriosclerotic process and other risk factors in the preoperative evaluation of patients being considered for intervention is extremely important.

History
A detailed history is important and should include information concerning coronary artery disease, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, hypercoagulable states, renal disease, strokes, unusual bleeding, hyperlipemia, and family history of atherosclerosis. Complete physical examination Special attention should be directed to the following. Bilateral arm pressures. Bilateral arm pressures may identify proximal upper extremity arterial occlusions that have direct effects on the ability to monitor patients' brachial arterial pressure in the perioperative period or ABIs long term. In addition, an unsuitable proximal inflow source for an axillofemoral bypass may be identified. Peripheral pulses. Determination of the presence and magnitude of peripheral pulses is helpful in the identification of the site of arterial occlusions, as well as for long-term monitoring. Aneurysm. It is important to identify aortic or peripheral aneurysms as sources of emboli and for appropriate management by either operation or observation. Bruits in the neck, abdomen, or groin. Bruits may identify stenotic lesions that require further evaluation.

284 DeWeeseet al. Laboratory testing Routine testing Blood tests. Appropriate preoperative laboratory testing includes determination of a complete blood count including a platelet count, prothrombin time, and partial thromboplastin time. A biochemical profile should include blood urea nitrogen, serum creatinine, serum cholesterol, and triglyceride levels. Other. A routine urinalysis, chest x-ray, and electrocardiogram are recommended. Special as indicated Coronary artery disease. Coronary artery disease is present in at least 70% of patients with symptomatic lower extremity vascular disease, of which approximately 20% is severe enough to warrant coronary revascularization.22,23 Furthermore, it is the most frequent cause of death during the early and late follow-up of patients who undergo surgery. The mortality rate from coronary artery disease for patients who undergo arterial reconstruction in collected series is approximately 15% at 5 years, 25% at 10 years, and 35% at 15 years. 19,24'2s In addition, the 10-year mortality rate for patients with and without known coronary artery disease who undergo surgery has been in the range of 69% to 92% versus 26% t o 65%. 19'2~'26 Available data do not currently permit an objective documentation of the benefits of prophylactic coronary bypass in this patient group for prolongation of life. However, physicians caring for patients with symptomatic lower extremity atherosclerosis must be concerned about coronary artery disease primarily because of its adverse effect on perioperative death and morbidity. 273 Significant symptoms include unstable angina pectoris, severe congestive heart failure and controlled arrhythmia, and recent myocardial infarction. In such patients any of the detailed preoperative tests listed below may be appropriate before performance of lower extremity revascularization.3133 Exercise stress electrocardiogram Exercise thallium cardiac scan Intravenous dipyridamole or adenosine thallium scan Multigated cardiac blood pool scan Long-term Holter monitor for evidence of silent ischemia Cardiac catheterization with coronary arteriography Therapeutic alterations resulting from such diagnostic information may include a decision to choose nonoperative treatment of lower extremity ischemia

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or employ a procedure of lesser magnitude, such as axillary-bifemoral bypass instead of aortobifemoral bypass. Specific cardiac treatment before lower extremity revascularization may include alteration of medications or fluid balance. Other treatments may include pacemaker insertion and coronary artery bypass grafting. 23,34,3sNumerous ongoing studies are attempting to define precisely the group of symptomfree patients who will most benefit by such detailed preoperative coronary studies. Clearly, extension of these expensive and frequently invasive diagnostic procedures to all patients undergoing vascular surgery presently appears unwarranted. Carotid artery disease. Widespread performance of carotid artery duplex scanning has resulted in definition of categories of stroke risk associated with varying degrees of carotid artery stenosis. Many believe that asymptomatic internal carotid artery stenosis of greater than 70% to 75% diamete, ~ reduction has a sufficiently high risk of stroke to justify prophylactic carotid endarterectomy?6-s8 At least one study suggests that the risk of perioperative stroke in patients with severe carotid stenosis is significant,39 although the incidence of stroke in patients with hemodynamically significant carotid stenosis in multiple other studies was not different from that found in patients without carotid stenosis. 4-42 It is known that 5% to 8% of patients being considered for cardiovascular surgery have carotid artery stenosis of greater than 75% diameter reduction.43 At present no randomized controlled trials have established the efficacy of treatment of such lesions in symptom-free patients by prophylactic carotid endarterectomy for either prevention of perioperative stroke or long-term stroke. Endarterectomy for patients both with and without symptoms with 70% to 75% stenosis is logical and preferable treatment before arterial reconstruction. 38'44 The experience of Freischlag et al.4s at~' Beebe et al.46 supports the performance of prophylactic endarterectomy on patients with 75% or greater diameter stenosis when the combined operative morbidity and mortality rates are less than 3%. Screening of patients scheduled for lower extremity revascularization to detect critical carotid artery stenosis should be performed for symptom-free parents with bruits and all patients with symptoms. Any of the methods listed below may be used. Carotid artery duplex scanning Oculopneumoplethysmography Continuous-wave Doppler with spectral analysis If any of these tests indicate the presence of critical

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carotid artery stenosis, carotid arteriography may be performed to confirm the diagnosis. Abdominal aortic aneurysm. The incidence of abdominal aortic aneurysm in patients with lower extremity occlusive disease is approximately 9%. 47 An abdominal ultrasound examination may be necessary in patients in whom the presence or absence of an aneurysm cannot be determined by abdominal examination because of the potentially lethal natural history of these aneurysms. Computed axial tomography and tho~:acicoabdominal aortography may also be required for planning of the operation. Diabetes mdlitus. The incidence of symptomatic lower extremil~ occlusive arterial disease was more than twice as great in diabetic compared with nondiabetic patients (4.3% vs 2%) in one epidemiologic study. 9 Approximately 16% of patients with claudication have diabetes. The foot salvage rate 3 ~cars after operation is only slightly better for nondiabetic compared with diabetic patients (93% vs 85%). 24 On the other hand, after the onset of symptoms of arterial insufficiency, the mortality rates at 5 years for diabetic patients is twice as great as that for nondiabetic patients (49% vs 23%). 9 It is important, therefore, to establish the diagnosis of diabetes to determine the long-term benefit of an operation. Fasting blood glucose levels and glucose tolerance tests are required if glucosuria is found. Pulmonary disease. Symptomatic lower extremity arterial occlusive disease is more common in cigarette smokers than ha nonsmokers (2.4% vs 1.4%). 9 Of greater importance is the fact that approximately 80% of patients with symptomatic disease are smokers. 9 Provan et al. 48 found that the 5-year patency rate for aortofemoral bypass grafts in nonsmokers was 71% and in those who stopped smoking 77%, compared with 42% for those who continued smoking. Myers et al.49 found patency rates of femo~mpliteal grafts at 4 years of 80% for nonsmokers and 61% for smokers. The 5-year mortality rate tbr patients with symptomatic disease who continue smoking is approximately 27% compared with 12% for those who quit. 49 The importance of smoking in decision making for operations and in the managemerit of patients operated on is obvious. In addition to chest x-rays, heavy smokers and patients with pulmonary symptoms should also be evaluated with arterial blood gases and pulmonary function tests. These tests should include vital capacity, maximum .b~'eathing capacity, and forced expiratory volume in 1 second. Hypertension. Approximately 23% of patients

with asymptomatic arterial occlusive disease have a history of, or currently have, hypertension. 9 There are no studies incriminating hypertension as adversely affecting morbidity or mortality rates or late graft patency in patients undergoing lower extremity arterial reconstruction, although hypertension is an important risk factor for both myocardial infarction and stroke. False aneurysms are more common in hypertensive patients. Coagulation abnormalities. All patients undergoing surgery for leg revascularization should undergo preoperative determination of platelet count, prothrombin time, and partial thromboplastin time. A clinical history of bleeding abnormality, onset of disease at less than 45 years of age, or a significant abnormality of any of the three tests warrants detailed coagulation consultation. It has become clear in recent years that a significant percentage of patients with either arterial occlusive disease or a history of recurrent venous thrombosis have detectable hypercoaguable abnormalities. Presently all patients with multiple prior episodes of lower extremity deep vein thrombosis or a prior failure of arterial reconstruction should undergo a screening battery of coagulation tests. This should include a determination of antithrombin Ill, protein C, protein S, anticardiolipin antibody, lupus anticoagulant, and lipoprotein A. Abnormalities of any of these screening tests suggests the need for a coagulation consultation. Donaldson et al. 5 found deficiencies of antithrombin III, protein C, and protein S and the presence of either lupuslike anticoagulant activity or heparin-induced platelet aggregation in 14 of 137 patients undergoing arterial reconstruction. ~ Thrombosis occurred within 30 days of operation in 27% of the 14 patients with positive test results and 1.6% of the 123 patients with normal results.
INTERVENTIONS F O R ARTERIAL DISEASES Arterial reconstruction

Several different surgical procedures are currently used for lower extremity revascularization. The factors influencing the choice of procedure are the nature of the lesions producing ischemia, the severity of ischemia, the urgency of the need for revascularization, the location of the responsible lesions, the availability of autogenous venous conduit, and the number and severity of associated medical conditions. The most frequently used procedures are listed below, with a brief description of the utility of each.

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Embolectomy. This is generally the procedure of choice for acute arterial occlusion with significant symptoms. In patients with documented embolization who have symptoms or minimal symptoms of anticoagulation without operative intervention as advocated by Blaisdell et al.,16 embolectomy may be appropriate. On occasion, patients with angiographically proved emboli may be treated with thrombolytic agents.S1 Risks associated with emboli are related to (1) the local ischemic insult, (2) the procedure used to restore circulation, and (3) recurrence with damage to another organ system. Stratification of risk with embolectomy has demonstrated a threefold to sevenfold increased mortality rate in patients older than 70 years. In recent years, overall mortality rates from arterial emboli have been reported in the range of 10% to 30%. Immediate surgical complications from emboli include amputation, which will be mandated in 5% to 25% of patients. Compartment syndrome, myoglobinuria, renal failure, contracture, and persistent ischemic neuropathy may also result, with a probability of occurrence related to the degree and duration of ischemia. Short- and long-term prevention of recurrent embolization mandates anticoagulation, with risk of wound hematoma and gastrointestinal or other hemorrhage. Anticoagulation will reduce the rate of reembolization from approximately 40% to 20%. 52'53 Endarterectomy. The role of endarterectomy is supported in aortoiliac bifurcation disease, common femoral disease extending to the deep femoral artery, and limited superficial femoral artery disease. Results in the aortoiliac system are comparable to those of bypass grafting with prosthetic materialfi4 In the femoropopliteal system some authors have reported results to be comparable to those of conventional bypass techniques for localized disease, sS's6 This has not been the experience of most vascular surgeons. In the reconstruction of tibial arteries, endarterectomy has little role because of vessel size, rarity of segmental involvement, and low flow rates leading to a higher rate of thrombosis, s7 Bypass grafts. Bypass grafting operations may be categorized as proximal procedures, distal procedures, or extraanatomic procedures. Proximal procedures bypass lesions proximal to the inguinal ligament to provide inflow to the common iliac, superficial, or deep femoral artery, whereas distal procedures bypass those lesions located distal to the common femoral artery. Extraanatomic procedures

are used in situations in which routing grafts along the normal course of the arteries is contraindicated, as in the case of infections, or relatively contraindicated, as in intracavitary procedures in patients with multiple risk factors. Bypass techniques have been employed since the later 1940s and are considered the "gold standard" against which all other varieties of reconstruction are compared. Proximal procedures. Aortic bypass for occlusive disease has been performed with synthetic prostheses since 1957. Proximally, these may be fashioned end to end or end to side to the native aorta. End-to-end anastomoses are preferred if the bypassed segment is aneurysmal, thrombosed, or a source for emboli. End-to-side anastomoses are employed to ensure flow to arterial branches proximal to the occluded aorta or iliac arteries. Distally the graft limbs are anastomosed end to side to the iliac or femoral artery, ensuring retrograde flow to vessels distal to occlusion. The distal femoral anastomosis must ensure excellent flow to the deep femoral artery and may require a profundaplasty. Results with aortofemoral reconstruction are excellent, with graft patency rates at 5 years ranging from 80% to 90% and at 10 years from 70% to 75%. s4 Distal procedures. Distal procedures may extend from the common femoral, superficial femoral, or deep femoral arteries to the above-knee or belowknee popliteal artery, infrapopliteal arteries, or arteries of the foot. Results with life-table analysis have been reviewed extensively in numerous clinical series. Bypasses with autogenous vein have demonstrated superiority in randomized trials. 5s Five-year secondary patency rates in excess of 70% are possible for reconstructions extending to the popliteal artery and in excess of 50% for grafts extending to the tibial arteries, s9 The reported limb salvage rate is 8 0 % ~ 90% at 5 years. The greater saphenous vein is the conduit of choice. Results achieved with other veins such as the lesser saphenous, arm vein, and superficial femoral vein are less satisfactory.6 Results achieved with various techniques of autogenous grafting, such~ as the in situ saphenous vein technique and reversed vein technique, have equal success in randomized trials. 61 Outflow procedures performed with prosthetic grafts are justified in some patients requiring above-knee bypasses if autogenous vein is not available. 5s Some patients with severe obstructive disease. may require combined inflow and outflow bypass grafts for reliable salvage of a failing foot. These

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extensive operations are best performed by multiple simultaneously operating teams. 62 Extraanatomic procedures'. In selected patients, extraanatomic grafts to restore inflow may be performed by femorofemoral, axillofemoral, axillobifemoral, or crossover iliofemoral technique. Axillofemoral bypass for aortoiliac occlusive disease provides 5-year patency rates of 40% to 70%, which is not as good as results of aortofemoral and iliofemoral bypass grafting. 54,63"66 However, patency rates of 75% to 80% at 3 to 4 years have been reported with the use of externally supported axillobifemoral prosthetic grafts. 67 The choice of a crossover iliofemoral or femorofemoral bypass as opposed to a unilateral iliofemoral bypass for an isolated lilac stenosis is stil] being debated. Patch angioplasty. For limited atherosclerotic stenoses or recurrent lesions with neointimal fibrous lyperplasia, patch angioplasty with or without localized endarterectomy may be indicated. This is used most frequen@ in the lilac, femoral, deep, and superficial femoral arteries and occasionally in the popliteal arteuz. In larger arteries, use of prosthetic material for angioplasty is justified, but for mediumsized arteries, including the deep popliteal and tibial arteries, autogenous vein or endarterectomized artery is preferred. Additional use of patch angioplasty is in the closure of longitudinal arteriotomies made for such procedures as embolectomy or open-balloon angioplasty.68 If the angioplasty technique is used for properly selected lesions, results are comparable to those of vein bypass. The most frequent site for patch angioplasty is the common femoral-deep femoral system. There reconstruction patency at 5 years for patients with daudication exceeds 75%. 69,70 Where the initial indication for reconstruction is limb salvage, results of profundaplasty are poorer, with , .year patency rates of 20% to 40%. Nevertheless, because it is a local procedure and leaves the patient with many furore options for reconstruction, it remains an attractive procedure for the inital management of selected patients with rest pain or small ischemic ulcers with poor runoff vessels or a lack of available suitable veins. Transluminal aJ~erial reconstruction In 1992 surgical interventions were complemented by several interventional radiographic techniques, one of which is generally accepted (percutaneous transluminal angioplasty [PTA] with a balloon) and some of which must still be considered

experimental (atherectomy and stenting of angioplasty sites). Results of surgery must be compared with those for other interventions in terms of benefits and risks. The choice of PTA is affected by the level of the arterial lesion: patency rates of iliac angioplasty are generally superior to those of femoral artery angioplasF. Precise analysis of data pertaining to PTA is difficult because (1) many early reports did not use criteria for patency comparable to those customarily used for vascular reconstructions, (2) many reports omitted standard life-table analysis, (3) many reports confused primary and secondary patency (i.e., the effect of a redilation), and (4) many reports did not inch:de the effect of initial dilation failure in the calculation of results. Nevertheless, available data support the following positions. For segmental common iliac lesions, the initial patency rate with PTA ranges from 90% to 95%. 7: The 5-year patency rate for common lilac PTA ranges from approximately 80% for single stenotic lesions to 50% to 60% in the presence of a diffusely diseased iliac artery. Percutaneous transluminal angioplasty of external iliac occlusions is initially successful in 70% to 90% of cases, with a 4-year patency rate ranging from 47% to 86%, all dependent on the length of the ocdusion.71, 72 In femoropopliteal disease PTA is initially successful in about 80% ofstenoses and 75% to 85% of occlusions treated. 7a Immediate patency depends on the length of the lesion, with patency rates approaching 70% at 5 years reported in the most favorable
CaSeS 72,73

The data regarding the restenosis rate requiring redilatation are unclear at present. It is generally accepted that redilation is possible for most lesions (63% in the lilac system and 47% in the femoropopliteal system). 74,7s If an experienced interventional angiographer trained to perform transturninal arterial reconstructions is available, balloon angioplasty ofiliac stenoses and short occlusions is appropriate for selected lesions. Percutaneous transluminal angioplasty in the infraingulnal vessels demands more technical skill but may be appropriate for selected lesions. The choice of balloon angioplasty versus surgery should be made with mutual consultation between the interventional angiographer and the vascular surgeon caring for the patient. 76 Laser-assisted balloon angioplasty has been generally abandoned. Intravascular stenting and atherectomy are procedures still under development and

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study for their clinical efficacy, long-term results, and cost-effectiveness. As such, their use may be appropriate for selected lesions, but these procedures should be applied only when careful follow-up procedures are in place to evaluate the long-term results. 76 Nonarterial operations Lumbar sympathectomy. A major indication for sympathectomy is in the management of reflex sympathetic dystrophy. In addition it may be used as an adjunct for the management of atheroembolism of the foot. Lumbar sympathectomy is extremely effective in properly selected patients. The range of mortality rates from sympathectomy is probably lower than the older reported 0% to 6 % . 77 The most serious local complications are postsympathectomy neuralgia, which may occur in as many as 50% of patients, and ejaculatory dysfunction, which occurs in 25% to 50% of patients. If the indication for sympathectomy is severe, nonreconstructible occlusive disease with limited tissue loss, healing will result only in approximately half of cases. Considering the natural history of such wounds, these results are equal to those obtained with careful wound care and administration of analgesics. Nevertheless, after a trial of proper wound care, if the risk of the procedure appears low, sympathectomy may be indicated in carefully selected patients, particularly those who show objective evidence of vasospasm. Fasciotomy. Fasciotomy is indicated when there is direct evidence for development of a compartment syndrome after ischemia. This is an adjunctive procedure rather than a primary reconstruction technique. Results will vary with the indications. If used for documented compartment syndrome, results will be related to the degree and duration of ischemia. Amputation. Primary amputation without an attempt at vascular reconstruction of a severely ischemia extremity should be uncommon. Of course primary amputation is a necessary option in the management of severe diabetic foot infections or in the presence of gangrene to a degree such that there is not enough viable tissue to ~llow salvage of a functional foot for walking. Primary amputation may be indicated also in severe ischemia where the physical status of the patient will never allow useful walking or pivoting for transfer with the salvaged foot. The mortality rate with major amputation is high,

ranging up to 30% in collected series. 7ss The risk is high because of patient selection: the majority of patients with a threatened limb are candidates for arterial reconstruction after which limb salvage will be achieved. Most patients who are not candidates for reconstruction have severe, debilitating generalized disease. Thrombolytic therapy There are several indications for thrombolysis in the management of peripheral vascular disease: (1) to restore circulation after acute arterial occlusion, with hope that a treatable cause for occlusion will be revealed that may then be treated with balloon angioplasty or surgery; (2) to restore an acutely thrombosed reconstruction, which may then be treated with balloon angioplasty or surgery; (3) to lyse arterial emboli to avoid surgical embolectom~ and (4) to be used in low doses during surgery as a?5 adjunct to thrombectomy. Results for the different indications are anecdotal at best. After acute graft thrombosis, dot lysis has been successful in 20% to 50% of cases, sl Lysis of clot after arterial embolization has been successful in as many as 80% of cases. 82 In acute bypass thrombosis, restoration of patency has been achieved in 20% to 75% of cases, but some 80% to 91% of these grafts will require an immediate secondary procedure to treat an underlying lesion that caused the thrombosis.81 The i2-month graft patency rate after these secondary procedures is a disappointing 20% to 40%. a3 Thrombolytic therapy has another advantage over catheter thrombectomy of autogenous vein grafts because of the reduced risk of myointimal injury. Finally, adjunct thrombolysis in the operative management of acute occlusion has been reported to be useful in as many as 75% of cases. 84 Serious complications have been reported with even low-dose thrombolytic therapy. H e m o r r h a ~ occurs in 8% to 24% of patients receiving streptokinaseY Hematomas occur in 6% to 20% of infusions. Systemic allergic reactions are particularly notable with streptokinase, occurring in up to 50% of infusions. Death related to drug administration has occurred in as many as 5% of infusions, mostly with streptokinase. 84 Urokinase is preferred. COMPLICATIONS Wound Bleeding. Reoperation for hemorrhage is re-~ quired after 1% to 3% of lower extremity reconstructions because of improper hematosis or coagulation

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disorder. 8s Significant wound hematomas are best managed by opening of the incision, evacuation of the hematoma, and reclosure under sterile conditions. Needle aspiration is inadequate and results in infection. Edema. Edema occurs in a majority of patients with infrainffainal revascularization, perhaps 70% at least, and results primarily from surgical disruption of lymphatics. 86 It tends to be minor and to resolve in 3 to 4 months. With reoperations, persistent arteriovenous fistulas with in situ bypass, and prior deep venous thrombosis, edema may be more severe. A sudden increase in edema may indicate a new episode of deep venous thrombosis. Lymphorrhea. Lymphorrhea occurs infrequently, in less than 5% of reconstructions. It may pose a risk for infection if prosthetic material is located within the leaking wound. Initial management includes bed rest, local occlusive wound dressings, systemic antibiotics, and prophylaxis against venous thrombosis. If these measures fall, it may be necessary to explore the wound, suture affected lymphatics, and reclose the wound carefully.87 Measures to prew:nt this complication include careful lymphostasis and the use of a lateral or medial approach to the groin without disruption of the primary collection of lymphatics and nodes overlying the femoral vessels. Skin necrosis. Skin necrosis occurs in as many as 8% of arterial reconstructions, a8 It is more common in the presence of diabetes, redo operations, and where vein har~est requires creation of thin skin flaps. Management includes local dressings to allow demarcation, wound debridement, and the occasional use of skin grafts or flaps for dosure, s9 Infection. The incidence of infection is approximately 1%. Risk factors include diabetes, redo operations, prosthetic material, hematoma, pro_)nged operation, distal sepsis in the limb, local sepsis in the groin, ongoing bacteremia, lymph drainage, :skin necrosis, skin flaps, improper closure of wound, ;and puncture site iIffection from angiography. Thrombosis and thromboembolism Venous thrombosis. The incidence of clinically significant venous thrombosis associated with lower extremity revascularization is remarkably low (i.e., ][%). This has been attributed to the extensive use of anticoagulants during surgery, which is the period of greatest venous stasis and greatest risk for developrnent of dots. Bypass thrombosis. Acute bypass thrombosis

within 30 days is reported in as high as 10% of all femoropopliteal and femorotibial reconstructions. 9 The incidence of arterial thrombosis within 1 month of reconstruction for such procedures as endarterectomy and angioplasty is similar.
False aneurysms

False aneurysms occur with an incidence of approximately 1% to 2% in late follow-up.9~ They are attributed to infection, suture failure, or degenerative change in the host artery with "pull through" of the suture from the artery wall. Progressive ischemia, gangrene after bypass The causes of progressive ischemia after arterial reconstruction are several. Hemodynamic failure. Hemodynamic failure occurs when a reconstruction is patent but delivers inadequate circulation to the distal extremity. Typical causes include the selection of an outflow level for the bypass that does not bridge all hemodynamically significant disease, thrombosis of the outflow arterial circulation such that the bypass primarily feeds retrograde into more proximal circulation, or distal occlusive disease that cannot be bypassed. Inflow stenosis. When a bypass is placed distal to severe aortoiliac disease, there may be enough restriction of flow through the inflow stenosis that, despite a patent graft flow, it is inadequate to relieve distal ischemia. Technical problems. Technical problems include stenosis in the bypass, anastomotic stenosis, improper tunneling with compression, retained clot in the reconstruction, improper valve incision, intimal flaps, and small bypass diameter. All can lead to functional bypass failure. 92 Atheroembolism. Microthromboembolic and cholesterol debris may be released accidentally into the circulation during manipulation of the arteries causing severe digital ischemia ("trash foot"). The incidence is ill defined but is probably between 1% and 5%. Initial management should be watchful waiting with anticipated improvement. Autoamputation of superficial distal digital lesions may occur. Formal amputation at the most distal level consistent with wound healing and salvage of fimction may become necessary. With proper early surveillance, detection, and early reoperation, these complications can be managed successfully. Progression of ischemia to the point of amputation will occur in less than 5% of patients.

290 DeWeese et aL Major morbidity and death Pulmonary embolism. The incidence of pulmonary embolism after distal reconstruction is unknown. It is likely less than 1%, perhaps related to the intraoperative use of anticoagulants. Stroke. The risk of stroke is low after lower extremity vascular reconstruction but still four to six times higher than after general surgery. In symptomfree patients with defined carotid disease, the risk of stroke is approximately 1%, and in those with symptomatic disease it is increased to approximately 4%, A cervical bruit alone is not a risk factor for stroke, Myocardial infarction. Approximately 70% of patients who undergo lower extremity revascularization have concomitant coronary artery disease. 22,23 The risk of perioperative myocardial infarction in patients undergoing vascular surgery is increased by the presence of a recent myocardial infarction, uncontrollable angina, pulmonary edema, and ventricular dysrhythmias. In the "best" group of patients the risk is only 4%, but in those with the worst symptoms morbidity and mortality rates exceed 7% 27,93 Death. Operative mortality rates range from 0% to 7.5% in various studies, although most indicate a mortality rate less than 3%. The best results are found in series with larger numbers of patients with claudication, and the worst results typically occur in patients with limb-threatening ischemia. Diabetes is an added risk factor. POSTOPERATIVE F O L L O W - U P OF PATIENTS U N D E R G O I N G L O W E R EXTREMITY REVASCULARIZATION Appropriate follow-up of patients undergoing lower extremity revascuiarization is lifelong, in recognition of the chronic progressive nature of the primary disease process, atherosclerosis. Ideally this follow-up should be performed by the operating surgeon. The majority of failures of lower extremity revascularizations occur within the first year after the procedure. 94 Therefore the number of follow-up visits during this interval should be greater than during subsequent years. Objective information concerning the patency of arterial repairs, as well as the status of native arteries in unoperated areas, should be obtained at every follow-up visit. The results should be subjected periodically to life-table analysis. 3 Pulse palpation alone is neither a reproducible nor a reliable indicator of satisfactory function of arterial repairs. Evaluation of the lower extremity circulation at follow-up visits can be obtained by noninvasive

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means, with the minimum acceptable measurement being an ABI. Autogenous vein bypass grafts should be examined by duplex scanning with determination of graft flow velocity. This parameter has been demonstrated to be a sensitive indicator of impending graft failure, which becomes abnormal before resting ankle pressure decreases or recurrent patient symptoms o c c u r . 96 The measurement of ABIs before and after exercise may also uncover significant stenoses not causing decreased ABIs at rest. Detection of such impending failure is important because multiple studies have demonstrated that the outcome of procedures to restore patency to thrombosed vein grafts is poor with respect to prolonged patency,81,95 whereas the outcome of procedures to correct stenoses in failing grafts before the occurrence of thrombosis is quite satisfactory.96,97Patients suspected of having stenoses in lower extremity venous bypass grafts shoui~ undergo arteriography if any of the following findings is apparent at the time of follow-up examination. 97 Recurrent symptoms of ischemia Loss of previously palpable pulse Decrease in anlde/brachial pressure ratio of greater than 0.20 below the highest postoperative value Duplex scan-determined graft flow velocity less than 45 cm/sec If arteriograms demonstrate a stenotic lesion in autogenous vein bypass grafts of greater than 60% diameter reduction, elective repair should be performed to prevent graft thrombosis. To date, similar criteria to detect stenoses developing in prosthetic grafts, or in endarterectomized native arteries, have not been developed. Ifstenoses are discovered in such reconstructions, prophylactic reoperation is prudent because of poor prognosis associated with attempts to restore flow to thrombosed grafts.
RESOURCES Operative procedures performed to treat lower extremity ischemia range in complexity from relatively minor procedures such as femoral embolectomy performed under local anesthesia to extraordinarily extensive operations on the aorta, iliac, and femoral arteries involving incisions into major body cavities, large swings in fluid balance, major blood loss, and many hours of general anesthesia. Similarly, the severity of illness treated may range from stable fife-style-limiting claudication in a relatively healthy middle-aged patient to acute severe limb ischemia occurring in an elderly patient with severe impair-

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ment of cardiac, pulmonary, and renal fimction. Given this tremendous range in magnitude of procedure and severity of illness, no absolute requirements for patient care and monitoring can be stated without also describing individual patient characteristics. Hospitals and physicians wishing to undertake lower extremi!ty revascularization must be prepared to care for the entire spectrum of lower extremity ischemia, however, because the nature of the primary disease process (i.e,, atherosderosis) implies multisystem involvement and the potential for major complications in all patients. Minimal capabilities for performance of lower extremity revascularization are listed.
Medical staff Given the advanced age and potential for multisystem disease, the ready availability of specialists in me following areas is optimal. Vascular surgery. Surgeons performing lower extremity revascularization should be eligible for or possess the Certificate of Special or Added Qualifications in General Vascular Surgery issued by the American Board of Surgery or have General Surgical certification and documented training or experience demonstrating competence in the performance of vascular surgev.~.98 Anesthesiology. Qualified specialists in anesthesiology are necessary to ensure adequate patient care during operations. Internal medicine. Complications of lower extremity ischemia predictably include myocardial infarction, congestive heart failure, arrhythmias, cardiogenic shock, renal failure, respiratory failure, severe soft tissue infections, and septic shock. Specialists in the following areas are necessary to provide consultation for optimal patient management: cardiology, nephrology, pulmonary medicine, and infec, _0us disease. Critical care. Trained specialists in critical care awe necessary for optimum patient management. Depending on the institution, this requirement may be met by the vascular surgeon or other surgical, medical, or anesthesia physicians. Radiology. Qualified angiographers with interventional skills are essential to provide the highquality arteriograms necessary for proper procedural planning. Hospital facilities Intensive care. Capability to provide the following patient care procedures is essential: complete

hemodynamic monitoring including central venous pressure, arterial pressure, and pulmonary artery pressure with cardiac output determination; electrocardiographic monitoring; respiratory care including respirator support, respiratory therapists, and blood gas analysis; hemodialysis; and constant infusion of vasoactive medications. Operating room. In addition to providing all necessary instruments for arterial surgery on vessels from the aorta to the pedal arteries, the operating room must provide capabilities for patient management, support, and monitoring equivalent to those listed under intensive care above. Doppler equipment must be available immediately. Duplex scarming equipment should also be available. Radiology. Facilities for complete operative arteriography including appropriate fluoroscopy and filming equipment and a complete assortment of catheters, guide wires, and monitoring equipment should be available. Inpatient care. Ideally, care of patients undergoing vascular surgery should be concentrated in an identified nursing unit with nursing staff oriented and skilled in the care of elderly patients with multisystem disease. Special training in recognition of cardiac and pulmonary complications and objective assessment of the peripheral circulation is desirable. Appropriate equipment including Doppler flow detectors and pressure cuffs must be available. The contributions of J. L. Kaufman, MD, and Lloyd M. Taylor, Jr., MD, are appreciatively acknowledged.
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30. Rivers SP, Scher LA, Gupta SK, et al. Safety of peripheral vascular surgery after recent acute myocardial infarction. J Vase SURG 1990;11:70-6. 31. Eagle K, Singer DE, Brewster DC, et al. Dipyridamolethallium scanning in patients undergoing vascular surgery: optimizing preoperative evaluation of cardiac risk. JAMA 1987;257:2185-9. 32. Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. N Engl I Med 1990;323:I781-8. 33. Makaroun MS, Shuman-Jackson N, Rippey A, et al. Cardiac risk in vascular surgery: the oral dipyridamole thallium test. Arch Surg I990;125:1610-3. 34. Foster ED, Davis KB, Carpenter JA, et al. Risk ofnoncardiac operation in patients with defined coronary disease: the coronary artery surgery study experience. Ann Thorac Surg 1986;41:41-50. 35. Rud GJ Jr, Cooley DA, Duncan JM, et al. The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients. J Vasc SUV, G 1986;3:788-98. 36. Roederer GO, Longlois YE, Jager KA, et al. The n a m r ~ history of carotid artery disease in asymptomatic patients wit}~ cervical bruits. Stroke 1984;15:605-13. 37. Moneta GL, Taylor DC, Nicholls SC, et al. Operative versus nonoperative management ofasymptomatic high-grade internal carotid artery stenosis: improved results with endarterectomy. Stroke 1987;18:1005-10. 38. Moore WS, Mohr JP, Najafi H, et al. Carotid endarterectomy: practice guidelines. J VAsc SUV, G 1992;15:469-79. 39. Kartchner MM, McRae LP. Carotid occlusive disease as a risk factor in major cardiovascular surgery. Arch Surg 1982;117: i086-8. 40. Barnes RW, Liebman PR" Marszalek PB, et al. Natural history of asymptomatic carotid disease in patients undergoing cardiovascular surgery. Surgery 1981;90:1075-83. 4!. Breslau PJ, Fell G, Ivey TD, et al. Carotid arterial disease in patients undergoing coronary artery bypass operations. j" Thorac Cardiovasc Surg 1981;82:765-7. 42. Turnipseed WD, Berkoff HA, Belzer FO. Postoperative stroke in cardiac and peripheral vascular disease. Ann Surg 1980;192:365-8. 43. Faggioli GL, Curl GR" Ricotta JJ. The role of carotid screening before coronary artery bypass. J VAse SUV, G 1990;12:724-31. 44. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy ~_~ symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-50. 45. Freischlag JA, Hanna D, Moore WS. Improved prognosis for asymptomatic carotid stenosis with prophylactic carotid endarterectomy. Stroke 1992;23:479-82. 46. Beebe HG, Clagett GP, DeWeese JA, et al. Assessing risk associated with carotid endarterectomy. Stroke 1989;20: 314-5. 47. Cabellon S Jr, Moncreif CL, Pierre DR. et al. Incidence of abdominal aortic aneurysms in patients with atheromatous arterial disease. Am J Surg 1983;I46:575-6. 48. Provan JL, Sojka SG, Murnaghan JJ, et al. The effect of cigarette smoking on the long term success rates of aortofemoral and femoropopliteal reconstructions. Surg Gynecol Obstet I987;165:49-52.

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49. Myers F.A, King RB, Scott DF, et al. The effect of smoking on the late patency of arterial reconstructions in the legs. Br I Surg 1978;65:267-70. 50. Donaldson MC, Weinberg DS, Belkin M, et al. Screening for hypercoagulable states in vascular surgical practice: a preliminary study. J VAse SURG 1990;1i:825-31. 51. Katzen BT, Edwards KC, Albert AS, et al. Low dose fibrinolysis in peripheral vascular disease. J Vase SURG 1984;1:718-22. 52. Elliott IP Jr, Hageman IH, Szilagyi DE, et al. Arterial embolization: problems of source, multiplicity, recurrence, and delayed treatment. Surgery 1980;88:833-45. 53. Green RM, DeWeese JA, Rob CG. Arterial embolectomy before and after the Fogarty catheter. Surgery 1975;77:2432. 54. Brewster DC. Direct reconstruction for aortoiliac occlusive disease. In: Rutherford RB, ed. Vascular surgery. 3rd ed. Philadelphia: WB Saunders, 1989:683. 55. InaharaT, Scott CM. Endarterectomy for segmentalocclusive disease of the superficial femoral artery. Arch Surg 1981;116: 1547-53. ~6. Ouriel K, Smith CR, DeWeese JA. Endarterectomy for localized lesions of the superficial femoral artery at the adductor canal. I Vasc SUV, G 1986;3:531-4. 57. Inahara T, Toledo AC. Endarterectomy of the popliteal artery for segmental occlusive disease. Ann Surg I978;188:43-8. 58. Veirh FJ, Gupta SK, Ascer E, et al. Six-year prospective multicenter r~ndomized comparison ofautologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J VASCSURG 1986;3:104-14. 59. Pomposelli FB Jr, Jepsen SJ, Gibbons GW, et al. Efficacy of the dorsal pedal bypass for limb salvage in diabetic patients: short term observations. J VAsc Suv,~ 1990;11:745-51. 60. Leather RP, Shah DM, Chang BB, Kaufman JL. Resurrection of the in-situ saphenous vein bypass: 1000 cases later. Ann Surg 1988;208:435-42. 61. Harris PL, How TV, Jones DR. Prospectively randomized clinical trial to compare in situ and reversed saphenous vein grafts for femoropopliteal bypass. Br J Surg 1987;74: 252-5. 62. Dalrnan R.L, Taylor LM Jr, Moneta GL, et al. Simultaneous operative repair of multilevel lower extremity occlusive disease. J VAse SU~,G1991;13:211-21. 63. Couch NP, C]owes AW, Whittemore AD, et al. The iliac origin arterial graft: a useful alternative for iliac occlusive disease. Surgery 1985;97:83-7. ~4. Kalman PG, Hosang H, Johnston DW, et al. The current role for femorofemoral bypass. I VAsc SUV, G 1987;6:71-6. 65. Parsonnet V, Alpert J, Brief DK. Femorofemoral and a~xillofemoral grafts: compromise of preference. Surgery I970;67:26-33. 66. Clark ET, Gewertz BL, Bassiouny HS, et al. Current results of elective aortic reconstruction for aneurysmal and occlusive disease. J Cardiovasc Surg 1990;31:438-41. 6,7. EI-Massry S, Saad E, Sauvage LR, et al. A twelve-year follow-up of axfllofemoral grafts. J VASC SUV, G (in press). 68. Rollins DL, Towne JB, Bernard VM, et al. Endarterectomized superficial femoral artery as an arterial patch. Arch Surg 1985;120:367-9. 69. Leather RP, Shah DM, Karmody AM. The use of extended profimdaplasty in limb salvage. Am J Surg 1978;135:13659.

70. Taylor LM Jr, Baur GM, Eidemiller LR, et al. Extended profundaplasty: indication and techniques with results of forty-six procedures. Am J Surg 1981;141:539-45. 71. Hasson JE, Archer CW, Wojtowycz M, et al. Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality. Surgery 1990;108:748-52. 72. Ahn SS, Eton D, Moore WS. Endovascular surgery for peripheral arterial occlusive disease. Ann Surg 1992;216:316. 73. Cambria RP, Faust G, Gusberg R, et al. Percutaneous angioplasty for peripheral arterial occlusive disease: correlates of clinical success. Arch Surg 1987; 122:283-7. 74. Wholey MH. Controversies in peripheral vascular intervention. Radiology 1990;174:929-31. 75. Becker GJ, Palmaz ~IC, Rees CR, et al. Angioplasty-induced dissection in human iliac arteries: management with Palmaz balloon-expandableintraluminalstents. Radiology 1990; 176: 31-8. 76. White RA, White GH, Mehringer MC, et al. A clinical trial of laser thermal angioplasty in patients with advanced peripheral vascular disease. Ann Surg 1990;212:257-65. 77. Collins GI, Rich NM, Claggett GP, et al. Clinical results of lumbar sympathectomy. Am Surg 1981;47:31-6. 78. Couch NP, David JK, Tilney NL, et al. Natural history of the leg amputee. Am J Surg 1977;133:469-74. 79. Evans WE, Hayes JP, Vermilion BD. Effect of a failed distal reconstruction on the level of amputation. Am J Surg 1990;160:217-20. 80. Keagy BA, Schwartz JA, Koth M, et al. Lower extremity amputation: the control series. J VAsc SURG 1986;4: 321-6. 81. Graor RA, Risius B, Young JR, et al. Thrombolysis of peripheral arterial bypass grafts: surgical thrombectomy compared with thrombolysis. J Vasc SUV, G 1988;7:34755. 82. O'Donnell TF Jr. The use ofthrombolytic therapy for failed synthetic and vein grafts. In: Veith FJ, ed. Current critical problems in vascular surgery, vol 2. St. Louis: Quality Medical Publishing, 1990:336-41. 83. Belkin M, Donaldson MC, Whitremore AD, et al. Observations on the use of thrombolytic agents for thrombotic occlusion of infrainguinalvein grafts. J VASCSUV, G 1990; 1 h 289-96. 84. VanBredaA, Katzen BT: Thrombolytic therapyofperipheral vascular disease. Semin Intervent Radiol 1985;2:354-8. 85. Malone JiM, Moore WS. Acute bleeding complications of vascular grafts. In: Haimovici H, ed. Vascular emergencies. New York: Appleton-Century-Crofts, 1982:471-8. 86. Persson NH, Takolander R, Bergquist D. Lower limb edema after arterial reconstructive surgery: influence of preoperative ischemia, type of reconstruction and postoperative outcomc. Acta Clair Scand 1989;155:259-66. 87. Bernhard VM, Towne JB, eds. Complications in vascular surgery. 2rid ed. New York: Grime & Stratton, 1987:56188. 88, Levine AW, Bandyk DF, Bonier PH, et al. Lessons learned in adopting the in situ saphenous vein bypass. I VAsc Suing 1985;2:145-53. 89. Kaufman JL, Shah DM, Corson JD, et al. Sartorius muscle coverage for the treatment of complicated vascular surgical wounds. J Cardiovasc Surg 1989;30:479-83. 90. Bandyk DF, Towne JB, Schmit DD, et al. Therapeutic options

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for acute thrombosed in situ saphenous vein arterial bypass grafts. J VASCSURG 1990i11:680-7. Clarke AM, Poskitt KR, Baird RN, et al. Anastomotic aneurysms of the femoral artery: aetiology and treatment. Br ] Surg 1989;76:1014-6. Berkowitz HD, Greenstein S, Barker CF, et al. Late failure of reversed vein bypass grafts. Ann Surg 1989;210:782-6. Eagle 1CA,Coley CM, NewellJB, et al. Combining clinical and thallium data optimizes preoperative assessment of cardiac risk before major vascular surgery. Ann Intern Med 1989;110: 859-64. Bandyk DF, Kaebnick HW, Stewart GW, et al. Durability of the in situ saphenous vein arterial bypass: a comparison of primary and secondary patency. J VASCSUWG1987;5:25668.

95. Veith FJ, Ascer E, Gupta SK, et al. Management of the occluded and failing PTFE graft. Acta Chir Scand 1987;538: 117-24. 96. Bandyk DF, Cato RF, Towne JB. A low flow velocity predicts failure of femoro-popliteal and femoro-tibial bypass grafts. Surgery 1985;98:799-809. 97. Green RM, McNamara J, Ouriel K, et al. Comparison of infrainguinal graft surveillance techniques. J V~sc SURG I990;11:207-15. 98. Moore WS, Treiman RL, Hertzer NR, et al. Guidelines for hospital privileges in vascular surgery. J VASe Suv,6 1989; 10:678-821 Submitted Jan. 5, 1993; accepted March 15, 1993.

LIFELINE

SOCIETY F O R VASCULAR SURGERY F O U N D A T I O N G R A N T AWARD

The Lifeline Foundation of the Society for Vascular Surgery invites grant applications for funding of meritorious research by young surgical investigators. The awards are intended for surgeons who have completed their formal surgical education in general surgery and who have completed or are in an advanced training program in vascular surgery. To be considered for selection a candidate: 1. Should be certified by the American Board of Surgery or have completed the requirements for certification 2. Should submit an application within 3 years of completion of an approved residency training program 3. Must have either a faculty appointment in an approved medical school in the United States or Canada or have received an academic appointment within the guidelines of the applicant's institution Grant awards are not intended to supplement salary, which will remai the responsibility of the institution in which the awardee holds an appointment. [[i.e awardee is expected to devote a significant amount of time to the funded project. A progress3 report will be presented by the investigators during the annual meeting of the Soci,:ty for Vascular Surgery. A grant awards committee will review competitive applications. It is anticipated .daat two grants will be awarded annually totaling $50,000 each to include indirect costs. Each award will be for 1 year with the option to extend for an additional year. Grant appfications may be obtained from: The Lifeline Foundation Society for Vascular Surgery Thirteen Elm St. Manchester, MA 01944 (508)526-8330

The deadline for receiving applications in the Foundation office is January 15,
1994. Funds will be awarded by July 1, 1994.