title: Endo first is not appropriate in some patients with critical limb ischemia because "bridges are burned".
abstract: BACKGROUND
  The aims of this study were to determine the effect of failed prior endovascular treatment (EV) on early and midterm outcomes of subsequent lower extremity open surgical (OS) bypass.
  
  
  METHODS
  Patients undergoing infrainguinal bypass for critical limb ischemia (CLI) from January 2008 to December 2011 were retrospectively reviewed. The results after first-line bypass and bypass after failure of EV treatment were compared. A total of 213 patients (65.25% men; average age, 73.30 years) underwent bypass. OS patients were then divided into 2 groups: group 1 consisted of 138 patients who underwent primary OS for CLI without prior EV (control group) and group 2 consisted of 75 patients who had OS after a failed attempt at elective EV for peripheral vascular disease. Of the 213 bypass performed, 34% had a prior infrainguinal failed EV. The primary study end points were early and 1-year major amputations and graft occlusion. The secondary outcomes included early and 1-year mortality and the level of distal revascularization.
  
  
  RESULTS
  Secondary patency and limb salvage rates were significantly better in group 1 up to 1 year (99% vs. 86%; P < 0.001 at 1 month and 95% vs. 76%, P < 0.05 at 12 months, respectively).
  
  
  CONCLUSIONS
  Previous failed EV should be predictive of poor outcome in patients undergoing distal OS for CLI.
authors.affiliation: Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy. Electronic address: frastilo@hotmail.com.
authors.forename: Francesco
authors.initials: F
authors.lastname: Spinelli
authors.affiliation: Division of Vascular Surgery, Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy.
authors.forename: Narayana
authors.initials: N
authors.lastname: Pipitò
authors.affiliation: Division of Vascular Surgery, University of Sassari, Sassari, Italy.
authors.forename: Eugenio
authors.initials: E
authors.lastname: Martelli
authors.affiliation: Division of Vascular Surgery, Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Benedetto
authors.affiliation: Division of Vascular Surgery, Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: De Caridi
authors.affiliation: Division of Vascular Surgery, Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Spinelli
authors.affiliation: Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Stilo
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects* / Q000401:mortality; D005260:Female; D006083:Graft Occlusion, Vascular / Q000209:etiology / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure; D014654:Vascular Patency