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Introduction: Pedal or distal crural bypass surgery for limb salvage is a method with very good long-term results. For patients in whom a suitable autologous venous graft is not available, the use of a venous allograft is an alternative procedure., Case Report: A 68 years old man with ischaemic disease of lower extremities and gangrene of the left foot was admitted to our Centre in August 2014. He underwent percutaneous transluminal angioplasty of crural arteries of his left lower extremity. This, however, failed to improve peripheral circulation. The patient was then indicated for pedal or distal crural vascular reconstruction. Since no suitable autologous vein was available, distal bypass surgery using a donor graft remained the only option for limb salvage. Amputation of the toes on the left foot due to gangrene was necessary. Subsequently, femoro-pedal bypass to the left common plantar artery was performed using a great saphenous vein allograft. The post-operative course was without complications, the pedal bypass was patent and toe amputation was with good healing. The patient remained in follow-up care., Conclusion: A good outcome of vascular reconstruction with an allograft depends on the availability of a suitable allograft and good patient compliance with post-operative care. In the case presented here, the pedal bypass grafting by means of an allograft helped to save the patients limb., Key Words: pedal bypass venous allograft limb salvage.

Introduction: The measurement of transcutaneous oxygen pressure (TcpO2) is a non-invasive method to quantify skin oxygenation at capillary level and their nutritive ability needed to heal the ischemic defect. TcpO2 pressure values below 30 mm Hg are specific for critical limb ischemia and predict complicated healing. The purpose of this study was to verify the cut-off pressure in patient unable to undergo vascular reconstruction, and to verify the possibility of using this method to evaluate the effectiveness of vascular reconstructive surgery., Methods: The group included 52 patients (35 men and 17 women). The mean age of patients in the group was 66.5 years (max. 85, min. 44)., Results: In our group of patients we confirmed that the TcpO2 values of successfully healed ischemic wounds were equal or greater than 30 mm Hg (mean TcpO2 value at the dorsum of the foot was 37.0 mm Hg ± 9.5 mm Hg), compared to the group of unsuccessfully healed patients whose values were lower (mean TcpO2 value at the dorsum of the foot was 9.0 mm Hg ± 5.3 mm Hg)., Conclusion: TcpO2 is a suitable method in predicting the healing of ischemic defects and any possible need for surgical or endovascular revascularization. Thanks to its non-invasive nature and undemanding measurement, it surely helps to make better decisions in choosing the therapeutic procedure needed to heal the defect.

Vasculitides are an etiologically heterogeneous group of vascular affections leading to vascular wall damage followed by ischaemia of the tissues supplied by the affected vessels. Damage to the vessels of lower extremities is frequent; in serious cases a complete destruction of soft tissue as well as skeletal lesions may occur. This then results in a situation which, without a well-timed surgical intervention, often requires an amputation of the limb. We are presenting a case of a 61-year-old female patient with a large plantar defect of the right foot and gangrene of three toes of the same limb which developed as a result of necrotizing vasculitis.

The authors present the case of a subadventitial rupture of the popliteal artery and devastating injury to the crural arteries due to a crush injury to the proximal shank. The arterial injury was treated by urgent popliteo-pedal bypass grafting. Besides the surgical procedure, the authors also discuss revascularisation syndrome. The subadventitial rupture of the popliteal artery is a serious condition associated with a risk of high amputation.

The authors present a rare complication of limb revascularization using pedal bypass, disruption of the surgical wound resulting from infectious etiology with bleeding from the distal anastomosis. The wound disruption was successfully managed by venous interposition grafting. The bypass patency, as well as full functioning of the extremity, were preserved.

Background: Pedal bypass grafting has been the method of choice at Na Homolce Hospital's Vascular Surgery Department since 2008., Methods and Results: During the period from June 2008 to December 2011, 29 pedal bypass procedures were performed in 27 patients. No perioperative mortality was recorded. Early occlusion of the graft occurred in three patients and two patients experienced delayed occlusion. Loss of the limb as a result of graft occlusion was unavoidable in two cases and one amputation had to be performed despite a patent graft. The primary patency rate for the period under review is 82.75%, and we were able to salvage the limb in 89.65% of cases. Follow-up results for our cohort are comparable with those from other centres dealing with the same problem., Conclusions: Pedal bypass has excellent early and long-term results and makes a significant contribution to reducing the number of major amputations of the lower limbs.

Skin defects and wounds are rather frequent in diabetic population. They most frequently occur on lower limbs and their origins are often multifaceted. If vascular perfusion is not damaged, it is important to secure perfect drainage with sufficient incision and to use local treatment modalities such as hyaluronan-iodine complex, now well-established at our clinic. It is always essential to save the vascular system if this is damaged. Careful examination by an angiologist is normally followed by angioplasty or vascular bypass. Amputation is an extreme solution that, nevertheless, may save the limb functionality if done in a patient with ischemic damage that cannot be resolved.

The authors evaluate a group of 110 patients to whom a pedal bypass was implanted in the period from October 2000 to July 2009. In all cases the limb was at risk of high amputation and the possibilities of endovascular and conservative therapy were exhausted. No patient died during the procedure, early postoperative mortality was 1.8%. During the follow-up (average, 30 +/- 26.4 months; range, 1.2-91.2 months) 21 bypass occlusions occurred, of which in 8 cases bypass patency was restored by an early intervention. In the reference period the cumulative probability of primary and secondary patency of pedal bypasses is 67.2% and 69.5%, the cumulative probability of limb salvage by pedal bypass surgery is 78.0%. A part of the study is a statistical evaluation of the data and findings of how the primary and secondary patency of pedal bypasses and the probability of limb salvage are influenced by diabetes mellitus.

In 2000 to 2002, we carried out "pedal" arterial reconstructions in 30 patients, performing a distal anastomosis to the dorsal pedal artery (47%) or the posterior tibial artery (53%). All patients suffered from critical ischemia of the lower extremity; 26 (86.7%) had gangrene or foot defect and 21 (70%) had diabetes mellitus. They all had atherosclerotic obliteration of the crural arteries and only a graft bypass of this segment offered good prospects for limb salvage. In 16.7% of the patients, previous percutaneous transluminar angioplasty had failed to treat the condition. Preoperative angiographic findings were unsatisfactory in the majority of patients because in 23 patients (76.7%) the plantar arch was not shown and, in 13 patients (43.3%), neither the plantar arch nor any of the pedal arteries were visualised. During 36 months of follow-up, one patient died (3.3%) and three had bypass graft occlusion (10%). Of these, one patient underwent early thrombectomy, which resulted in long-term graft patency and limb salvage. A further patient had the limb saved although occlusion occurred after the defect had healed. In the third patient, however, bypass occlusion eventually led to high amputation of the leg. The results were evaluated by Kaplan Meier analysis. At 36 months, cumulative probabilities were 87% and 90% for primary and secondary patency, respectively; cumulative probability for limb salvage was 93%. Our results are in agreement with those from major specialised foreign centres and support the view that patients with critical ischemia and unsatisfactory angiographic findings (obliteration of crural arteries) are indicated for pedal artery inspection with subsequent vascular reconstruction.

Aim: The aim of this retrospective analysis was assessment of both patency and limb salvage rates of diabetic ischemic feet which underwent pedal bypass surgery within the period of 3 years., Material and Methods: Authors evaluated 50 critically ischemic diabetic feet where the pedal bypass was indicated for limb salvage. Total 41 pedal bypasses were performed and median follow-up was 16.7 months (1-39). The free muscle transfer were performed either in one session with or subsequently after the pedal bypass surgery in six limbs., Results: Authors achieved 61% and 76% graft patency and limb salvage rates, respectively, within the median 16.7 months follow-up. All successfully revascularised feet healed up within the median period of 3 months postoperatively. No patient died within 30 days postoperatively., Conclusion: We conclude, that pedal bypass is safe procedure with acceptable limb salvage rate in the medium-term follow-up. Surgeons can markedly extend an indication criterions for limb salvage by exploiting of this technique.

The authors present their results of the treatment of diabetic foot critical ischemia by means of surgical revascularisation together with minor amputation or debridement. They discuss the causes of higher amputations and re-amputations in revascularised ischemic diabetic lower limbs and presents patency rates in different types of peripheral arterial bypasses. The authors evaluated 81 diabetic feet with chronic critical ischemia, where they performed 50 arterial bypass procedures in the 50 limbs (13 femoropopliteal, 13 femorodistal, 19 pedal bypasses and 5 aorto/ilicofemoral or extraanatomical bypasses). 41 minor amputations or debridements (82%), 6 minor re-amputations (12%) was performed in the group of 50 revascularised limbs. The primary patency rates, secondary patency rates and limb salvage was achieved 92%, 92% and 92% in femoropopliteal bypass, 91%, 91% and 92% in femorodistal bypass, 78%, 83% and 84% in pedal bypass, respectively. The average follow-up time was 11.4 months. 6 minor re-amputations (12%) and 5 high amputations was necessary to perform in the group of 50 revascularised lower limbs. The main cause of re-amputation and high amputation was continuing ischemia. 30 day mortality rate was 0%, 30 day morbidity rate was 8% (myocardial infarction and pulmonary embolism).

A formerly established theory on obliteration of diabetic foot arteries was dismissed. In the last decade, diabetic foot revascularization using so called very distal bypass has became a routine procedure. The reconstructions are undertaken in patients with chronic critical limb ischemia. This paper presents our initial experience with this, not yet widely used, operative technique in 16 patients who had a total of 14 pedal bypass procedures performed. The parameters we monitored included the 3-, 6-, and 12-month patency rates, defect healing, and limb salvage rates. The primary and secondary patency rates were 64.3% and 78.6% at 3 months; 55.5% and 66.7% at 6 months; and 50% and 75% at one year, respectively. The overall limb salvage rate for the above periods was 92.9%. All defects healed following successful revascularization using pedal bypass. In patients where bypass could not be established, limb salvage was accomplished in one in three cases only.

The authors pay attention to the evaluation of drainage in indications of femoropopliteal reconstructions with regard to the patency of the peripheral circulation. Based on comparison of preoperative arteriographic findings regarding the patency of venous femoropopliteal bypasses in 149 operated patients the authors were able to confirm their previous assumption that when evaluating the drainage it is necessary to take into consideration not only the number of patent arteries on the leg but also the patency of their continuation in the area of the sole where they form the plantar arch. When evaluating the drainage it is thus necessary to evaluate the patency of the entire complex: arteries of the leg+plantar arch. From this ensues the authors' demand to use in indications of femoropopliteal reconstructions as a basis arteriography which visualizes the entire peripheral arterial circulation incl. the plantar arch.