title: Factors that predict site of outflow target artery anastomosis in infrainguinal revascularization.
abstract: BACKGROUND
  Lower extremity revascularization is indicated for limb salvage and incapacitating leg claudication. Many risk factors (age, hypertension, diabetes, tobacco use, dyslipidemia, etc) have been associated with atherosclerosis and the development of peripheral arterial occlusive disease. However, whether these risk factors or the surgical indication (claudication or limb salvage) influences the extent and location of infrainguinal disease and hence the target artery (distal anastomosis) is unclear. This study examines the risk factors and indication for infrainguinal revascularization with respect to the type of bypass performed.
  
  
  METHODS
  Three hundred fifty-two infrainguinal revascularizations in 282 patients were retrospectively reviewed. Patient data, including demographics, cardiovascular risk factors, indications, types of revascularization, and perioperative complications and mortality, were collected. Data were analyzed with t test, chi(2) test, Fisher exact test, and multiple logistic regression.
  
  
  RESULTS
  The indication for surgical revascularization was claudication in 70 patients and limb salvage in 282. The likelihood of a popliteal anastomosis (above or below knee) versus a tibial or pedal anastomosis was decreased with increasing age (P =.002) and diabetes (P =.0001), and smoking increased the likelihood (P =.056). However, popliteal bypass also was strongly associated with claudication as the surgical indication (odds ratio [OR], 8.7; P =.0001), and 90% of the claudicant group had undergone popliteal anastomosis. Claudication and popliteal anastomosis were both linked to smoking; 97% of subjects who underwent operation for claudication were smokers compared with 75% of subjects who underwent tibial or pedal anastomosis for limb salvage (P =.001). After adjustment for indication, the likelihood of popliteal anastomosis was still decreased with diabetes (OR, 0.46; P =.002), and age had a borderline significant effect (P =.077). When the analysis was stratified by indication for surgery, the likelihood of popliteal bypass among patients who underwent operation for claudication was not influenced by age, diabetes, or smoking. However, within the subset of patients who underwent operation for limb salvage, the likelihood of any popliteal anastomosis was diminished by diabetes (OR, 0.50; P =.007), age (OR, 0.968 per year; P =.01), and chronic renal insufficiency (OR, 0.476; P =.04).
  
  
  CONCLUSIONS
  Infrainguinal peripheral arterial occlusive disease is not a homogenous disease entity. Claudication and limb salvage are associated with two distinct patterns of vascular disease with different risk factors. Patients who undergo operation for claudication are seen at an earlier age, have a high prevalence of smoking, and have proximal disease and a greater likelihood of a popliteal anastomosis. In contrast, patients for limb salvage are less likely to have a popliteal bypass, favoring a more distal target outflow anastomosis that is strongly influenced by advanced age, diabetes, and chronic renal insufficiency.
authors.affiliation: Department of Surgery, Section of Vascular Surgery D506, Boston University Medical Center, One Boston Medical Center Place, Boston, MA 02118-2393, USA. joseph.raffetto@bmc.org
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Raffetto
authors.forename: Morgan N
authors.initials: MN
authors.lastname: Chen
authors.forename: Wayne W
authors.initials: WW
authors.lastname: LaMorte
authors.forename: Craig S
authors.initials: CS
authors.lastname: Seidman
authors.forename: Robert T
authors.initials: RT
authors.lastname: Eberhardt
authors.forename: Jonathan
authors.initials: J
authors.lastname: Woodson
authors.forename: Gary W
authors.initials: GW
authors.lastname: Gibbons
authors.forename: James O
authors.initials: JO
authors.lastname: Menzoian
mesh_terms: D000368:Aged; D001166:Arteriovenous Shunt, Surgical; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000601:surgery*; D007866:Leg / Q000098:blood supply*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016491:Peripheral Vascular Diseases / Q000601:surgery*; D011150:Popliteal Artery / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D016909:Tibial Arteries / Q000601:surgery