Pedal bypass versus tibial bypass with autogenous vein: a comparison of outcome and hemodynamic results.
OBJECTIVE
Autogenous vein grafts to infrapopliteal arteries performed for chronic limb-threatening ischemia between 1984 and 1991 were reviewed to determine whether bypasses to pedal arteries produce results comparable to those obtained after supramalleolar tibial or peroneal bypasses.


METHODS
Pedal bypass (dorsal pedal, n = 41; below-ankle posterior tibial, n = 12) was performed only if a suitable tibial target artery was not available. These grafts were compared with tibial (including peroneal) bypass grafts (n = 203). All grafts were placed for rest pain (23%) or established tissue loss (77%).


RESULTS
Patients requiring pedal bypass were more likely to have diabetes and congestive heart failure but less likely to have a history of smoking. Age, gender, previous myocardial infarction, and other comorbidities were similar in the two groups. Operative mortality rates (30 days) were higher for pedal than tibial bypasses (9% vs 2%; p = 0.021), possibly reflecting the higher prevalence of diabetes, congestive heart failure, and more advanced systemic atherosclerosis associated with severe tibial artery disease. Most grafts were in situ saphenous vein (70% pedal vs 79% tibial). Life-table 3-year primary graft patency (58% pedal vs 61% tibial), secondary patency (82% pedal vs 79% tibial), limb salvage (92% pedal vs 87% tibial), and patient survival (61% pedal vs 64% tibial) were comparable in the two groups. Improved assisted primary patency and secondary patency rates in both groups were primarily a result of revision of graft-threatening lesions detected with noninvasive graft surveillance before thrombosis. Mean postoperative ankle/brachial index was similar for pedal and tibial bypasses, whereas mean duplex-estimated graft flow was less for pedal grafts (88 +/- 10 ml/min vs 129 +/- 6 ml/min; p = 0.002). Pedal bypass represented 21% of our experience with infrapopliteal vein grafts for chronic limb-threatening ischemia and was required more frequently in diabetic patients. Operative mortality rates were higher in patients undergoing pedal bypass, suggesting that aggressive preoperative diagnostic studies and perioperative monitoring may be appropriate for this group. Long-term survival was similar.


CONCLUSIONS
We conclude that autogenous vein pedal bypass grafts provide hemodynamic results and limb salvage rates comparable to more proximal tibial bypasses in properly selected patients.
Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, N.H.
J R
JR
Schneider
D B
DB
Walsh
M D
MD
McDaniel
R M
RM
Zwolak
S R
SR
Besso
J L
JL
Cronenwett
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001158:Arteries / Q000601:surgery; D005260:Female; D005528:Foot / Q000098:blood supply*; D006439:Hemodynamics; D006801:Humans; D007511:Ischemia / Q000601:surgery*; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000502:physiology / Q000637:transplantation*; D015996:Survival Rate; D016909:Tibial Arteries / Q000503:physiopathology / Q000601:surgery*; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000379:methods / Q000401:mortality