title: Pedal bypass surgery after crural endovascular intervention.
abstract: BACKGROUND
  Many centers choose endovascular intervention as their first-line treatment for crural occlusions in patients with critical limb ischemia (Rutherford 4-6). However, unsuccessful interventions often result in major amputation. Therefore, pedal bypass surgery should be considered as an alternative first-line treatment. We reviewed the impact of a prior endovascular intervention on the outcome of our patients' pedal bypass procedures.
  
  
  METHODS
  A retrospective analysis was conducted for all patients who had undergone pedal bypass surgery in our department from February 2008 to October 2012. We performed 75 pedal bypass operations in 71 patients (male, 54; female, 17; median age, 72 years; range, 29-90 years). In 36 of those cases, patients had undergone a prior infrapopliteal endovascular intervention (PEI group). In 39 cases, patients underwent bypass surgery as first-line treatment because their prior angiography had resulted in either unsuccessful endovascular intervention, or intervention had been deemed 'not feasible' (BSF group). Only autologous vein grafts were used, and no retrograde intervention was done via the pedal arteries. Endpoints of the analysis were primary and secondary patency rates, mortality, and limb salvage at 1 year postoperatively.
  
  
  RESULTS
  Overall primary patency at 1 year was 58.3%, and secondary patency was 61.3%. Limb salvage was 76.8% and survival was 80.4%. Graft occlusion within 30 days was 18.7%. Revision in those cases was futile and 78.6% of patients had to undergo major amputation. Primary patency at 1 year was 67.0% in PEI group vs 48.3% in BSF group (P = .409) and secondary patency was 73.5% vs 48.6% (P = .100). Prior endovascular intervention had no significant impact on either limb salvage (82.3% vs 71.6% at 1 year; P = .515) or graft occlusions within 30 days (19.4% vs 17.9%; P = .547). Survival rate at 1 year was 79.5% in PEI group and 81.3% in BSF group (P = .765). Risk factors and indications were similar in both groups.
  
  
  CONCLUSIONS
  Crural endovascular intervention does not seem to have a negative impact on the outcome of subsequent pedal bypass surgery. Requirements are avoiding a destruction of the target vessel and opting for timely bypass surgery whenever endovascular treatment does not achieve a sufficient perfusion for wounds to heal. Early graft occlusions are associated with a higher risk for major amputation.
authors.affiliation: Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany. Electronic address: christian.uhl@barmherzige-regensburg.de.
authors.forename: Christian
authors.initials: C
authors.lastname: Uhl
authors.affiliation: Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Carolin
authors.initials: C
authors.lastname: Hock
authors.affiliation: Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Betz
authors.affiliation: Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Ingolf
authors.initials: I
authors.lastname: Töpel
authors.affiliation: Department of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany.
authors.forename: Markus
authors.initials: M
authors.lastname: Steinbauer
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D000792:Angiography; D001157:Arterial Occlusive Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001807:Blood Vessel Prosthesis; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D005500:Follow-Up Studies; D005858:Germany / Q000453:epidemiology; D006083:Graft Occlusion, Vascular / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D006085:Graft Survival; D006801:Humans; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies; D012501:Saphenous Vein / Q000637:transplantation; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome