title: Early and one-year results of infrainguinal bypass after failure of endovascular therapy.
abstract: OBJECTIVE
  The aim of this study was to retrospectively compare early and one-year results of open surgery (OS) for critical limb ischemia (CLI) in patients who underwent primary surgery and in patients operated after a previous failure of endovascular treatment (EV).
  
  
  METHODS
  Between January 2004 and December 2007, 460 patients (304 males, 156 females) aged between 46 and 95 (average age 72) underwent OS or EV for CLI. We performed 273 EV (47%) and 307 OS (53%) procedures. In 98 patients (21.3%) the procedures were bilateral. EV procedures were intraluminal, subintimal or both, with selective stenting. OS procedures were distal bypass grafts. OS involved 34 dialysed patients, 159 patients with CLI non-dialysed and not previously submitted to EV treatment (group 1, control group) and 114 patients with failure of previous EV treatment (group 2), frequently performed in different and non surgical centers, 8% of EV failure in our series in this time. We retrospectively compared the early and one-year results in the last two groups of patients in terms of level of revascularization, primary patency, amputation and mortality.
  
  
  RESULTS
  By-pass grafts were autologous vein in 94% and PTFE in 6%. Revascularizations have been directed to the tibial or to the plantar arteries at the ankle or foot. Those directed to the plantars were respectively 54% (52% dorsalis pedis, 36% retromalleolar posterior tibial, 12% medial plantar artery) in the control group and 76% (66% dorsalis pedis, 18% retromalleolar posterior tibial, 16% medial plantar artery) in patients with previous failed PTA (P<0.001). Early primary patency, mortality and amputation free survival were respectively in the control group and in patients with previous failure of PTA: 93.7% vs. 76.3% (P<0.001), 2.5% vs. 3.5% (P>0.5), 95% vs. 93% (P>0.5). One-year primary patency, mortality and amputation free survival were respectively in the control group and patients with previous failure of PTA: 86.03% vs. 70.87% (P>0.25), 14.93% vs. 17.56% (P>0.5), 78.1% vs. 68.5% (P>0.1).
  
  
  CONCLUSIONS
  After failure of EV therapy, the subsequent open surgery was more distal and technically demanding. Its results were significantly worse when compared with standard CLI patients, with an increase rate of redo. Our data suggest that EV should not be attempted as the first choice in every patient affected by CLI, and we believe that OS still is the primary treatment for the most advanced clinical situations.
authors.affiliation: Unit of Vascular Surgery, Department of Thoracic and Cardiovascular Surgery, University of Messina, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Spinelli
authors.forename: F
authors.initials: F
authors.lastname: Stilo
authors.forename: F
authors.initials: F
authors.lastname: Benedetto
authors.forename: G
authors.initials: G
authors.lastname: De Caridi
authors.forename: M
authors.initials: M
authors.lastname: La Spada
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D017130:Angioplasty / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D007558:Italy; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D015607:Stents; D016019:Survival Analysis; D015996:Survival Rate; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency; D014680:Veins / Q000637:transplantation