The efficacy of salvage interventions on threatened distal bypass grafts.
OBJECTIVE
Infrapopliteal bypass is an established and effective method for limb salvage in patients with critical limb ischemia. Secondary interventions maybe required to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions.


METHODS
Consecutive patients undergoing bypasses onto the infrapopliteal vessels for critical limb ischemia (Rutherford 4-6) at a single institution were analyzed between 2009 and 2013. The primary end points were graft patency, amputation-free survival (AFS), and freedom from reintervention at 12 months by Kaplan-Meier analysis.


RESULTS
A total of 114 infrapopliteal bypasses were performed in 102 patients. Distal anastomosis was on to the anterior tibial (n = 31), posterior tibial (n = 27), peroneal (n = 24), tibioperoneal trunk (n = 23), or dorsalis pedis artery (n = 9). Primary patency, assisted primary patency, and secondary patency was 57%, 76%, and 82%, respectively, at 12 months and 44%, 70%, and 80%, respectively, at 36 months. AFS was 80% at 12 months and 65% at 36 months. Endovascular salvage interventions were performed on 58 grafts (51%) including angioplasty of inflow/proximal anastomosis (33%), outflow/distal anastomosis (46%), and graft stenosis (20%), with a further 12 grafts (11%) undergoing thrombolysis for occlusion. Surgical salvage interventions included jump grafts (n = 7), revision of anastomotic stenosis (n = 3), and thrombectomy (n = 2). AFS was similar in salvaged threatened and acutely occluded grafts compared with nonthreatened grafts (P = .064) and better in grafts requiring reintervention later (>6 months from bypass) compared with those requiring early reintervention (<6 months; P = .047).


CONCLUSIONS
Secondary interventions in threatened distal bypass grafts are successful at maintaining graft patency and AFS when compared with nonthreatened grafts, and are associated with a low morbidity rate.
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom. Electronic address: drsanjaypatel@hotmail.com.
Sanjay Dhanji
SD
Patel
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Vassilios
V
Zymvragoudakis
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Lisa
L
Sheehan
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Talia
T
Lea
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Soundrie
S
Padayachee
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Tommaso
T
Donati
Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Konstantinos
K
Katsanos
Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
Hany
H
Zayed
D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016638:Critical Illness; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006083:Graft Occlusion, Vascular / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D011150:Popliteal Artery / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012501:Saphenous Vein / Q000503:physiopathology / Q000637:transplantation*; D016909:Tibial Arteries / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects* / Q000401:mortality; D014654:Vascular Patency