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Wo steht der pedale Bypass heute?

Where does the pedal bypass stand today?

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Zusammenfassung

Seit mehreren Jahrzehnten stellt der autologe Venenbypass auf Arterien des Fußes eine wichtige Option zum Extremitätenerhalt bei chronisch kritischer Extremitätenischämie, insbesondere beim Diabetiker dar. 1‑Jahres-Offenheitsraten von 50–80 % und Beinerhaltungsraten von >80 % haben die Effektivität dieser periphersten Form der chirurgischen Gefäßrekonstruktion unterstrichen. Die zunehmenden Möglichkeiten der endovaskulären Behandlung von Stenosen und Okklusionen der Unterschenkelarterien haben die Rolle des pedalen Bypasses deutlich zurückgedrängt. Die geringere Invasivität mit mutmaßlich reduzierter Morbidität und Letalität lassen perkutane Angioplastien in dieser Indikation primär attraktiver erscheinen. Dennoch zeigen gerade neuere Untersuchungen, dass die primäre Revaskularisation des Fußes durch einen Bypass („straight line to the foot“) eine effektivere und durablere Abheilung von Fußwunden zu ermöglichen scheint. Die Einhaltung des Angiosom-Konzepts spielt dabei jedoch im Vergleich zur endovaskulären Therapie wahrscheinlich eine geringere Rolle. Diagnostische Verfahren wie die Duplexsonographie und die kontrastmittelverstärkte Magnetresonanzangiographie können wichtige ergänzende Verfahren zur Detektion anschlussfähiger Fußarterien sein. Neben der V. saphena magna kommen alternative, autologe Bypassgrafts wie Armvenen und die V. saphena parva in Betracht. Eine langfristige Überwachung der Funktion der pedalen Bypässe wird immer wieder empfohlen. Um auch zukünftig den Stellenwert dieser wichtigen Option zur Behandlung einer chronisch kritischen Extremitätenischämie bewerten zu können, sind dringend weitere Studien erforderlich.

Abstract

For decades autologous bypass surgery to arteries of the foot has been an option for revascularization in critical limb ischemia, particularly in diabetic patients. The 1‑year patency rates of 50–80 % and limb salvage rates of more than 80 % have proven the effectiveness of this type of peripheral vascular reconstruction; however, the growing importance of endovascular management of stenosis and occlusions of crural arteries has substantially lowered the role of pedal bypass surgery. Less invasiveness with reduced morbidity and mortality render percutaneous angioplasty techniques more attractive compared to open surgery, but recent data suggest that primary revascularization by bypass surgery (“straight line to the foot”) may provide a more effective and sustained healing of pedal wounds; however, adherence to the angiosome concept probably plays a minor role in comparison to endovascular treatment. Diagnostic measures, such as duplex ultrasound and contrast-enhanced magnetic resonance imaging may serve as important complimentary methods for detection of suitable pedal target vessels. Apart from the great saphenous vein alternative autologous grafts, such as arm veins and the small saphenous vein can be used. Long-term surveillance of pedal bypasses has widely been recommended. More studies are warranted for a better understanding of the future role of this type of bypass surgery in critical limb ischemia.

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  1. Klinik für Gefäßchirurgie, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Deutschland

    Richard Kellersmann

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Correspondence to Richard Kellersmann.

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Kellersmann, R. Wo steht der pedale Bypass heute?. Gefässchirurgie 23, 13–18 (2018). https://doi.org/10.1007/s00772-017-0350-z

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