Arterial Reconstruction: Femoral, Popliteal Tibial, Peroneal

One of the major causes of prob lems of the diabetic foot is vascular insufficiency. New modes of diagnosis and treatment have led to improved circulation and have bypassed amputation. It is well established that diabetes often accelerates the development of arteriosclerosis , particularly in the arteries of the lower extremity . This results in poor arterial blood supply and may produce symptoms of claudication , ischemic rest pain , and eventually gangrenous ulcers of the toe(s) or foot. Many years ago the progression of arterial disease and limb loss was accepted as inevitable because there was no capability for replacing the occluded arteries and no interest in pursuing the problem because the disease was thought to be generalized so where would the replacement start or end? With the development of arteriographic techniques , it was discovered that the generalized pattern of arterial narrowing was not the case and that often a segment of artery might be narrow or occluded, but open artery of adequate dimensions might be present proximally and distally. The French surgeons were the leaders in devising and carrying out surgical operations to help patients with these problems. The technique of anastomosing vessels had been developed by Carrel in 1906 but had applied only to salvage injured arteries. In the early 1950's, Carrel's teachings were utilized in placing artery grafts to re-establish arterial flow. At first, short blocks were sought for the diseased artery resected, and a graft salvaged from the corpse of a young person who had died of injuries or perhaps a brain tumor. The grafts were kept frozen and sterilized in plastic bags by means of cathode radiation . Soon we gave up resecting the diseased arterial segment, (usually located in the adductor canal), divided the artery above and below the block, and sutured the graft in place . The next advance was to use the end-toside anastomosis which tremendously increased the scope of arterial surgery . Now a graft could originate as a side branch from aorta , iliac, or common femoral artery without interfering with the function of that artery . Of further help is the fact that arterial disease involves primarily the posterior walls of arteries leaving soft anterior surfaces for suturing. The next step in the advance of surgical capability was the discovery that the saphenous vein was strong enough and , in most people, large enough (4 mm at the smallest end when gently distended) to serve as an artery . Meanwhile, the search for a plastic or other type of graft was pursued to obviate the need for tediously removing the saphenous vein or for use in those patients without an adequate vein. The search still continues with only modest success. Neither plastic nor preserved umbilical vein grafts serve as well as does the patient's own saphenous or cephalic vein, though the gap between the two modalities is narrowing. It should be mentioned that the cephalic vein was found to make an excellent graft , but that it is considerably more difficult to work with due to the fact that its wall is so thin.