title: Bypass to the ankle and foot in the era of endovascular therapy of tibial disease. Results and factors influencing the outcome.
abstract: OBJECTIVE
  Endovascular therapy (ET) is the treatment of choice for critical limb ischemia (CLI) and tibial arteries disease (TAD) in focal lesions with restorable run-off; ankle and foot bypass (BPG) is indicated in patients unfit for ET with foot or ankle arteries suitable for surgery. The aim of this study was to evaluate limb salvage (LS), primary patency (PP) and survival (S) of patients underwent BPG in the era of ET for TAD and to define the correlated prognostic factors.
  
  
  METHODS
  Between February 2000 and November 2008, patients with CLI and TAD were collected prospectively in a data-base (demographics, Fontaine's stage, Texas University Wound Classification [TUC]of ulcers, risk-factors, TAD, techniques of foot revascularization and surgical factors). BPG was performed in tibial arteries occlusion longer than 4 cm or focal occlusion without line-flow to pedal arteries. Clinical and Duplex-ultrasound follow-up was performed at discharge, 1, 3, 6 months and every 6 months. LS, PP, and S rates were assessed with Kaplan-Meier method; factors influencing outcomes were sought by multivariate Cox proportional hazards model analysis.
  
  
  RESULTS
  A total of 410 revascularizations were performed in patients with CLI and TAD; BPG in 153 patients (mean age: 69.3±10.6, male/female=117/36, diabetes mellitus=75.2% hyperlypidemia=54.9%, hypertension=87.6%, renal disease=32.7%, coronary arteries disease=51.6%, Fontaine stage IV=96.1%, TUC grade-III=65.4%, TUC stage-D=51%). All autologous grafts in 96.7% (non-reversed saphenous vein=74.5%, reversed=7.2%, composite vein graft=12.4%, arm's veins=2.6%). LS and S after 1 month were 88.2% and 97.1%, respectively. Mean follow-up was 23 months. At 12 and 36 months: LS 76.7% and 70.9%, PP 62.3% and 52.9%, S 91.5% and 74.6%. LS was negatively associated with age (HR=1.041 [95%CI=1.005-1.079]), infected ulcers (HR=3.377 [95%CI=1.571-7.258]), run-off arteries diameter <1.8 mm (HR=5.854[95% CI=2.274-15.070]). PP was negatively associated with hyperlipidemia (HR=2.555 [95% CI=1.418-4.603]), female gender (HR=2.125[95% CI=1.182-3.823]), run-off arteries diameter <1.8 mm (HR=6.165 [95% CI=2.774-13.699]), reversed saphenous graft (HR=3.105 [95% CI=1.166-8.272]), composite vein graft (HR=2.930 [95% CI=1.406-6.107]) and homograft (HR=2.762 [95% CI=1.040-7.333]); instead it is positively related with hypertension (HR=4.229 [95% CI=2.089-8.563]). S was negatively correlated with renal disease (HR=3.035 [95% CI=1.363-6.756]).
  
  
  CONCLUSIONS
  BPG may be a reasonable first treatment for CLI patients with TAD unfit for ET; female gender, hyperlipidemia, use of reversed saphenous, composite vein or alternative grafts, foot infection and renal disease are associated with worse outcome.
authors.affiliation: Vascular Surgery, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy - mauro.gargiulo2@unibo.it.
authors.forename: M
authors.initials: M
authors.lastname: Gargiulo
authors.forename: F
authors.initials: F
authors.lastname: Giovanetti
authors.forename: C
authors.initials: C
authors.lastname: Bianchini Massoni
authors.forename: A
authors.initials: A
authors.lastname: Freyrie
authors.forename: G
authors.initials: G
authors.lastname: Faggioli
authors.forename: N
authors.initials: N
authors.lastname: Muccini
authors.forename: A
authors.initials: A
authors.lastname: Stella
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000842:Ankle / Q000098:blood supply*; D003251:Constriction, Pathologic; D057510:Endovascular Procedures / Q000009:adverse effects; D005260:Female; D005528:Foot / Q000098:blood supply*; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012039:Regional Blood Flow; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation*; D016909:Tibial Arteries / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D058017:Vascular Grafting / Q000009:adverse effects; D014654:Vascular Patency