title: Outcomes of native superficial femoral artery chronic total occlusion recanalization after failed femoropopliteal bypass.
abstract: OBJECTIVE
  When a bypass fails, the options are lysis, redo bypass, or endovascular intervention. If lysis of the original bypass is not considered an option, which is better-redo bypass or attempts at endovascular recanalization of the native system? This retrospective study examined the outcomes of native superficial femoral artery (SFA) chronic total occlusion (CTO) recanalization compared with redo bypass after failed femoropopliteal bypass.
  
  
  METHODS
  Patients presenting with a symptomatic failed femoropopliteal bypass that underwent attempted CTO endovascular (EV) recanalization of the native SFA or a redo femoropopliteal bypass (BP) from 2000 to 2015 were analyzed. Patients undergoing catheter-directed thrombolysis were excluded. Time-dependent outcomes were assessed with life-table analyses. Factor analyses were performed using a Cox proportional hazard model for time-dependent variables.
  
  
  RESULTS
  A total of 104 patients (69% male; average age, 65 years) underwent EV (n = 40) or BP (n = 64) after presentation with symptomatic occlusion of a previous femoropopliteal bypass graft (rest pain in 84% and life-style limiting claudication in 16%, 79% to the above-knee popliteal, 81% prosthetic). According to the TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease classification, 91% of the lesions were category D and 19% were category C. Tibial runoff was one tibial vessel in 79% of the patients and two or more runoff vessels in the remainder. Lesions treated endovascularly underwent primary stenting with a median of 3 stents used. Of the bypasses performed, 69% were to the below knee popliteal and remainder were to the proximal tibials (68% of the patients had a venous conduit). At 30 days in EV vs BP, major adverse cardiovascular events were 3% and 8% (P = .24), major adverse limb events were 25% and 11% (P = .01), and the amputation rate was 8% and 8% (P = .96), respectively. Amputation-free survival was 33% ± 9% and 56% ± 8% (P = .02) and freedom from major adverse limb event was 19% ± 8% and 46% ± 7% (P = .04) at 3 years for EV vs BP, respectively.
  
  
  CONCLUSIONS
  In a high-risk cohort when thrombolysis is excluded, BP is superior to EV after failure of a femoropopliteal bypass.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Tex. Electronic address: daviesm@uthscsa.edu.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Davies
authors.affiliation: Division of Vascular Diseases and Surgery, Ohio State University, Columbus, Ohio.
authors.forename: Hosam F
authors.initials: HF
authors.lastname: El-Sayed
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects* / Q000401:mortality; D002908:Chronic Disease; D003251:Constriction, Pathologic; D057510:Endovascular Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007383:Intermittent Claudication / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D007511:Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D015993:Life Tables; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D011150:Popliteal Artery / Q000000981:diagnostic imaging / Q000601:surgery*; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D017211:Treatment Failure; D014680:Veins / Q000637:transplantation*