Advanced Ischemia

The markedly ischemic extremity, with femoral, popliteal, and tibial atherosclerotic occlusive disease, continues to present a challenge to the vascular surgeon. The extent of disease, length of segments involved, small size and construction of the vessel walls make direct restoration and maintenance of patency difficult. Improvements in techniques of vascular surgery have reached the point, however, that many extremities can now be salvaged that otherwise would have been amputated.1-13 The pathologic physiology is variable. Gradually developing diffuse stenosis of the femoral, popliteal, and tibial vessels may produce marked encroachment on the lumen before symptoms become apparent. Progression at one or more areas may then lead to severe arterial insufficiency. Localized involvement of the vessel, complicated by acute superimposed thrombosis is usually not tolerated, particularly if followed by thrombotic extension into the lower leg vessels. Trauma or infection may precipitate ulceration or gangrene in an ischemic extremity with localized or