Surgical Management: Open Surgical Treatment of Infra-Inguinal Occlusive Disease

  • Hisham RashidEmail author
  • Raghvinder Gambhir
  • Hani Slim


Infra-inguinal occlusive disease in diabetic and non-diabetic patients without treatment carries a significant risk of minor and major amputation as well as death. There are different modalities in treating peripheral arterial disease including bypass surgery and angioplasty. Several investigations have studied the outcomes in both modalities. Hybrid techniques using different revascularisation strategies have also been used especially in complex and redo- cases.

In this chapter the authors are addressing the different diagnostic modalities in critical leg ischaemia and the planning of surgical treatment in these patients. The outcome of distal and ultra-distal bypass surgery in the literature is also examined and the means of improving bypass outcome and follow-up are highlighted. Finally the role of arterial bypass and other modalities is briefly discussed in the treatment of acute lower limb ischaemia.


Critical ischaemia Bypass Angioplasty Amputation Wound healing Outcomes Mortality acute ischaemia 


  1. 1.
    Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, et al. BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366(9501):1925–34.CrossRefGoogle Scholar
  2. 2.
    Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, et al. on behalf of the BASIL trial Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 2010;51: 5S–17S.Google Scholar
  3. 3.
    Menard MT, Farber A, Assman SF, Choudhry NK, Conte MS, Creager MA, et al. Design and rationale of the best endovascular versus best surgical therapy for patients with critical limb ischemia (BEST-CLI). Trial J Am Heart Assoc. 2016;5(7):e003219. Scholar
  4. 4.
    TASC. Management of peripheral arterial disease (PAD). Trans Atlantic Inter-Society Consensus (TASC). Eur J Vasc Endovasc Surg. 2000;19(Suppl A):Si-xxviii, S1–250.Google Scholar
  5. 5.
    Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR, on behalf of the TASC II Working Group. TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vasc Endovasc Surg. 2007;33 Suppl 1:S1–75.Google Scholar
  6. 6.
    Aboyans V, Ricco JB, Bartelink ML, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral, Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J. 2018;39(9):763–816. Scholar
  7. 7.
    Slim H, Tiwari A, Ritter JC, Rashid H. Outcome of infra-inguinal bypass grafts using vein conduit with less than 3 millimeters diameter in critical leg ischemia. J Vasc Surg. 2011;53(2):421–5.CrossRefGoogle Scholar
  8. 8.
    Slim H, Tiwari A, Ahmed A, Ritter JC, Zayed H, Rashid H. Distal versus ultra-distal bypass grafts: amputation-free survival and patency rates in patients with critical leg ischaemia. Eur J Vasc Endovasc Surg. 2011;42(1):83–8.CrossRefGoogle Scholar
  9. 9.
    Tiwari A, Slim H, Edmonds M, Ritter JC, Rashid H. Outcome of lower limb distal bypass in Afro-Caribbean populations. Vasc Endovasc Surg. 2011;45(6):514–8.CrossRefGoogle Scholar
  10. 10.
    Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJ. Trends and outcomes after surgical lower limb revascularization in England. Br J Surg. 2011;98(10):1373–82.CrossRefGoogle Scholar
  11. 11.
    Green D, Bidd H, Rashid H. Multimodal intraoperative monitoring: an observational case series in high risk patients undergoing major peripheral vascular surgery. Int J Surg. 2014;12(3):231–6.CrossRefGoogle Scholar
  12. 12.
    Dosluoglu HH, Lall P, Cherr GS, Harris LM, Dryjski ML. Role of simple and complex hybrid revascularization procedures for symptomatic lower extremity occlusive disease. J Vasc Surg. 2010;51(6):1425–35.CrossRefGoogle Scholar
  13. 13.
    Davies AH, Hawdon AJ, Sydes MR, Thompson SG. VGST Participants. Is duplex surveillance of value after leg vein bypass grafting? Principal results of the Vein Graft Surveillance Randomised Trial (VGST). Circulation. 2005;112(13):1985–91.CrossRefGoogle Scholar
  14. 14.
    Gerhard-Herman, M. D., Gornik, H. L., Barrett, C., Barshes, N. R., Corriere, M. A., Drachman, D.E et al. (2016). 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2016; 135(12), e686-e725.Google Scholar
  15. 15.
    Treatment for Acute Limb Ischemia. J Vasc Surg. 2000;31(Suppl 1):S150–1.
  16. 16.
    Blaisdell FW. The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review. Cardiovasc Surg. 2002;10:620–30.CrossRefGoogle Scholar
  17. 17.
    Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26:517–38.CrossRefGoogle Scholar
  18. 18.
    Comerota AJ, Weaver FA, Hosking JD, Froehlich J, Folander H, Sussman B, et al. Results of a prospective, randomized trial of surgery versus thrombolysis for occluded lower extremity bypass grafts. Am J Surg. 1996;172:105–12.CrossRefGoogle Scholar
  19. 19.
    Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG. Intersociety consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45(Suppl S):S5–S67.CrossRefGoogle Scholar
  20. 20.
    Berridge DC, Kessel D, Robertson I. Surgery versus thrombolysis for acute limb ischaemia: initial management. Cochrane Database Syst Rev. 2002;(3):CDd002784.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Vascular SurgeryKing’s College Hospital Foundation TrustLondonUK

Personalised recommendations