Revisiting Microsurgical Distal Bypass for Critical Limb Ischemia

Abstract

Background The purpose of this study was to investigate the efficacy of introducing microsurgical techniques to distal bypass surgery for critical limb ischemia.

Methods Datasets of 83 consecutive microsurgical distal bypasses in a multicenter (SKY) study were compared with the results of the PREVENT III (PIII) study regarding the following: (1) patients' characteristics, (2) clinical severity according to the PIII risk score, (3) conduits and procedures for revascularization, (4) proximal and distal anastomosis sites, and (5) primary patency and amputation-free survival (AFS) rates at 1 year.

Results The high-risk group in the SKY study was larger compared with that in the PIII study (37 vs. 9%, respectively; p < 0.0001). Although all patients underwent revascularization in the perimalleolar region (100 vs. 65.1%, respectively; p < 0.0001), the primary patency rate at 1 year was 71.8%, compared with 59.9% in the PIII study (p = 0.0227). The AFS rate at 1 year was not significantly different between the SKY and PIII studies (80.6 vs. 75.1%, respectively; p = 0.189); however, there was a significant difference between the high-risk subsets of each group: 74.1% in the SKY study and 45% in the PIII study (p < 0.0001).

Conclusions Our data demonstrated that microsurgical distal bypass is an effective and durable procedure, especially for high-risk patients. We believe that microsurgical techniques should be considered for distal bypass to optimize the treatment of ischemic limbs with severe peripheral artery disease.

Keywords

distal bypass - critical limb ischemia - limb salvage

• References

• 1 Conte MS. Challenges of distal bypass surgery in patients with diabetes: patient selection, techniques, and outcomes. J Vasc Surg 2010; 52 (3, Suppl) 96S-103S
• 2 Adam DJ, Beard JD, Cleveland T , et al; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366 (9501) 1925-1934
• 3 Beard JD. Which is the best revascularization for critical limb ischemia: Endovascular or open surgery?. J Vasc Surg 2008; 48 (6, Suppl) 11S-16S
• 4 Tanaka Y, Sung K, Oda A, Kurosaki Y. Limb salvage by microsurgical distal arterial reconstruction of the foot in patients with diabetes and ischemic ulcers. The Japan J Plast Reconstr Surg 2005; 48: 601-610
• 5 Banis Jr JC, Richardson JD, Derr Jr JW, Acland RD. Microsurgical adjuncts in salvage of the ischemic and diabetic lower extremity. Clin Plast Surg 1992; 19 (4) 881-893
• 6 Quiñones-Baldrich WJ, Colburn MD, Ahn SS, Gelabert HA, Moore WS. Very distal bypass for salvage of the severely ischemic extremity. Am J Surg 1993; 166 (2) 117-123 , discussion 123
• 7 Gloviczki P, Bower TC, Toomey BJ , et al. Microscope-aided pedal bypass is an effective and low-risk operation to salvage the ischemic foot. Am J Surg 1994; 168 (2) 76-84
• 8 Conte MS, Bandyk DF, Clowes AW , et al; PREVENT III Investigators. Results of PREVENT III: a multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery. J Vasc Surg 2006; 43 (4) 742-751 , discussion 751
• 9 Schanzer A, Mega J, Meadows J, Samson RH, Bandyk DF, Conte MS. Risk stratification in critical limb ischemia: derivation and validation of a model to predict amputation-free survival using multicenter surgical outcomes data. J Vasc Surg 2008; 48 (6) 1464-1471
• 10 Schanzer A, Goodney PP, Li Y , et al; Vascular Study Group of Northern New England. Validation of the PIII CLI risk score for the prediction of amputation-free survival in patients undergoing infrainguinal autogenous vein bypass for critical limb ischemia. J Vasc Surg 2009; 50 (4) 769-775 , discussion 775
• 11 Oresanya L, Makam AN, Belkin M, Moneta GL, Conte MS. Factors associated with primary vein graft occlusion in a multicenter trial with mandated ultrasound surveillance. J Vasc Surg 2014; 59 (4) 996-1002
• 12 Berceli SA, Chan AK, Pomposelli Jr FB , et al. Efficacy of dorsal pedal artery bypass in limb salvage for ischemic heel ulcers. J Vasc Surg 1999; 30 (3) 499-508
• 13 Hughes K, Domenig CM, Hamdan AD , et al. Bypass to plantar and tarsal arteries: an acceptable approach to limb salvage. J Vasc Surg 2004; 40 (6) 1149-1157
• 14 Aulivola B, Pomposelli FB. Dorsalis pedis, tarsal and plantar artery bypass. J Cardiovasc Surg (Torino) 2004; 45 (3) 203-212
• 15 Slim H, Tiwari A, Ahmed A, Ritter JC, Zayed H, Rashid H. Distal versus ultradistal bypass grafts: amputation-free survival and patency rates in patients with critical leg ischaemia. Eur J Vasc Endovasc Surg 2011; 42 (1) 83-88
• 16 Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. J Vasc Surg 2015; 61 (1) 162-169
• 17 Treiman GS, Lawrence PF, Rockwell WB. Autogenous arterial bypass grafts: durable patency and limb salvage in patients with inframalleolar occlusive disease and end-stage renal disease. J Vasc Surg 2000; 32 (1) 13-22
• 18 Reed AB, Conte MS, Belkin M, Mannick JA, Whittemore AD, Donaldson MC. Usefulness of autogenous bypass grafts originating distal to the groin. J Vasc Surg 2002; 35 (1) 48-54 , discussion, 54–55
• 19 Ballotta E, Renon L, De Rossi A, Barbon B, Terranova O, Da Giau G. Prospective randomized study on reversed saphenous vein infrapopliteal bypass to treat limb-threatening ischemia: common femoral artery versus superficial femoral or popliteal and tibial arteries as inflow. J Vasc Surg 2004; 40 (4) 732-740