11/5/2008 1

Limb salvage in extensive leg gangrene

EMILIO CALABRESE MD.

International Center for Limb Salvage

www.gfmer.ch/ICLS/Homepage.htm

11/5/2008 2August 11, 1998

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Diarrhea produced by prolonged antibiotic treatmentRehydration was needed and control of diarrhea had to be achieved

before revascularization procedures could be initiated

11/5/2008 4Occlusion of superficial femoral artery

Popliteal artery reconstituted by collaterals just above the knee

11/5/2008 5August 11, 1998

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September 1, 1998Operative field with plastic sealing of the gangrenous area

The bypass had to be performed through a tunnel

underneath the ulcerated areas

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Femoral proximal anastomosis

Inverted contralateral saphenous vein bypass

11/5/2008 8Popliteal infragenicular distal anastomosis

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Cristiana Quattrone MD as surgeon and Vittorio Petralia RN

involved in a limb salvage procedure

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September 1, 1998

Leg status shortly after operation

11/5/2008 11September 5, 1998

4 days post op

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September 21, 1998

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October 21, 1998

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October 28, 1998

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November 10, 1998

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December 9, 1998Split Thickness Skin Grafts

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4 days after skin grafting

December 14, 1998

11/5/2008 18January 13. 1999

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March 8, 19993 months after skin grafting

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June 26, 19996 months after skin grafting

11/5/2008 21One-year after the bypass a proximal graft stenosis developed

It was treated by PTA and stenting with two coronary stents

Vein graft

stenosisThe vein graft has

been dilated and

stented

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11/5/2008 23Good distal bypass runoff after stenting

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June 29, 1999

X-ray 4-day after coronary stents insertionNote: more recent data suggest that this type of stent should not be used in this

superficial postion because they are balloon-expandable, not self-expandable,

and are subject to external pressure.

In fact these stents crashed and eventually occluded

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September 20, 1999

Long term skin graft results in the gangrenous area

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April 3, 2000

19 months after limb salvage procedure

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28-month after operation the bypass eventually occluded

11/5/2008 28January 17, 2001

A hybrid procedure is performed

isolating the femoral artery at the groin in the angio suite

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The native femoral artery is re-opened by stenting

11/5/2008 30Distal run-off after re-opening the native femoral artery

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June 1, 2001

Some edema, but no ulcer and no pain 3-year after limb salvage

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Conclusions

Extensive gangrene of the leg can be sometimes be treated with a venous bypass in proximity of damaged areas

Uncovered tendons can be surrounded by granulation tissue and may ultimately heal

Antibiotic abuse may cause severe side effects

Long term limb salvage can be achieved

When a bypass eventually fails, PTA and stenting could still be done, opening either the bypass itself or the native vessels

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Follow-up

Frequent examination of limb status

Further intervention at the first sign of

recurrent skin lesions

Long term limb salvage may be achieved

even if the bypass occludes after several

months with the help of interventional

endovascular procedures