Value of continued efforts at limb salvage despite multiple graft failures

Contemporary Outcomes following Redo Autogenous Infrainguinal Bypass

BACKGROUND

Revascularization after lower extremity bypass failure poses many challenges. Despite nearly 7 decades of experience with lower extremity revascularization, there is little data on the success of redo bypass particularly when autogenous conduit is utilized. The purpose of this study is to review outcomes of redo infrainguinal bypass constructed solely of autogenous vein.

METHODS

All patients who underwent redo infrainguinal bypass at a single institution by a single surgeon were retrospectively reviewed. Bypasses were categorized into 3 groups: femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Since the repeat bypasses were all done for limb salvage, freedom from above or below knee amputation (FFA) was primary outcome, which was defined as the number of days from redo bypass to subsequent amputation or the most recent follow-up.

RESULTS

From 2006 to 2016, 100 limbs underwent redo bypass. Fifty-nine (59.0%) limbs had undergone one previous bypass while 41 (41.0%) had undergone 2 or more. The redo configurations consisted of 23 (23.0%) femoral-popliteal, 70 (70.0%) femoral-distal, and 7 (7.0%) popliteal-distal bypasses. Ninety-seven (97.0%) underwent redo using autologous vein grafts including 41 (95.5%) of those who had 2 or more previous bypasses. The 3 patients who ultimately underwent prosthetic bypass had bilateral great and small saphenous veins and bilateral basilic and cephalic veins previously harvested. Nine (9.0%) limbs were subsequently amputated: 2 (2.0%) above knee and 7 (7.0%) below knee amputations. Of these, all had had 2 or more previous bypasses and 2 of the 3 patients who ultimately received prosthetic bypasses were in this group. In patients with one previous bypass, FFA was 775 days (IQR: 213-1,626 days). In patients with 2 or more previous bypasses, FFA was 263 days (IQR: 106-1,148 days). No patients with femoral-popliteal bypasses suffered amputation while 7 (10.0%) of the femoral-distal and 2 (28.6%) of the popliteal-distal bypasses suffered subsequent amputations (P = 0.067).

CONCLUSIONS

Redo infrainguinal bypass is effective in salvaging threatened lower extremities. Furthermore, once a patient is deemed a bypass candidate, revascularization with autologous vein can be achieved. A significant FFA rate is achieved with redo bypass, although patients with more distal disease are harder to salvage.

Repetitive bypass and revisions with extensions for limb salvage after multiple previous failures

The optimal treatment of patients facing imminent amputation after multiple (≥2) failed prior ipsilateral bypasses is unclear. We analyzed a group of patients undergoing multiple lower extremity bypasses for limb salvage to assess the utility of attempting multiple revascularizations. From 1990 to 2005, 105 revascularization procedures were performed in 55 limbs of 54 patients with imminent limb-threatening lower extremity ischemia after failure of ≥2 prior infrainguinal bypasses in the same leg. Fifty-five operations were the third procedure (Group A) and 50 operations were the fourth or more (Group B). We compared primary/secondary patency and limb salvage rates by Society for Vascular Surgery criteria. Limb salvage rates did not differ between patients undergoing a third bypass and those undergoing four or more bypasses at one year (62 versus 65%, NS) or at three years (58 versus 61%, NS). Secondary patency was not different between groups (76 versus 76%, P = NS) at one and three years (71 versus 70%, NS). Primary patency also did not differ between the two groups, at one year (24 versus 35%, NS), or at three years (11 versus 15%, NS). No differences were observed in morbidity and mortality rates between the groups. In conclusion, the likelihood of success of repetitive limb revascularization was unrelated to the number of previous failures. The expected incremental failure rate with each successive bypass was not found. These results, coupled with the three-year limb salvage rate of over 50% in patients who otherwise would have required amputation, lend support to aggressive use of limb revascularization in selected patients even after two or more failed bypasses.

Proportion of Patients with Critical Limb Ischemia who Require an Open Surgical Procedure in a Center Favoring Endovascular Treatment

Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.

Redo infrainguinal bypass: factors predicting patency and limb salvage

The increased complexity of redo infrainguinal bypass procedures can result in prolonged operative time and increased morbidity. This review was undertaken to compare outcomes from primary and redo bypass procedures and to identify factors predictive of graft failure and limb loss after redo bypass. All infrainguinal bypasses ( n = 468) from 1995 to 1999 were reviewed. A total of 367 primary bypasses in 317 patients were compared to 101 redo grafts in 84 patients with previously failed bypasses. Risk factors and types of procedures were compared using Student's t-test and the chi(2) test. Patency and limb salvage were compared using life-table analysis. Patients requiring redo bypasses were less likely to have diabetes and end-stage renal disease. Two-year patency (66 +/- 4% primary vs. 55 +/- 7% redo, p = 0.13) and limb salvage (75 +/- 3% primary vs. 72 +/- 6% secondary, p = 0.43) were comparable between primary and redo bypass groups. Female gender was predictive of redo graft failure (2-year patency 73 +/- 8% male vs. 39 +/- 9% female, p = 0.01). Clinical indications that predicted failure of a redo bypass included thrombosis of an autologous graft (1-year patency 71 +/- 7% previous prosthetic vs. 49 +/- 10% previous autologous, p = 0.004), thrombosis of an infrageniculate bypass (2-year patency 65 +/- 10% suprageniculate vs. 46 +/- 9% infrageniculate, p = 0.044), and a limb salvage indication for the primary operation (2-year patency 86 +/- 9% claudication vs. 44 +/- 8% limb salvage, p = 0.008). When a primary bypass fails despite the use of optimal conduit (autologous vein) and an infrageniculate target vessel, the redo bypass has a higher risk of failure, particularly in female patients. Nonetheless, patency and limb salvage rates justify an attempt at revascularization after failed primary bypass.

Outcome of catheter-directed thrombolysis for lower extremity arterial bypass occlusion

OBJECTIVE

The purpose of this study was to determine the clinical outcome of patients undergoing catheter-directed thrombolysis (CDT) for lower extremity arterial bypass (LEAB) occlusion.

METHODS

A retrospective review was performed of two university-based practices from 1988 to 2001. All patients with LEAB occlusion (<14 days by history) undergoing CDT as initial treatment were included. Technical success, complications, secondary patency, and limb salvage were examined. Additional analysis examined secondary procedures performed for residual lesions or failed CDT and the number of LEABs that were replaced or that became infected.

RESULTS

One hundred four patients (77% male; mean age, 65 years) had 109 LEAB occlusions. CDT restored patency in 77%. Of the 25 LEABs that failed initial CDT, 15 underwent surgical thrombectomy/revision, four were replaced, and six underwent no further interventions. Of the 84 LEABs successfully lysed, 51 had residual lesions that underwent revision with interventional (n = 30) or surgical (n = 15) techniques or both (n = 6). Median hospital stay was 8 days with three periprocedural deaths. One quarter of CDT procedures had bleeding or thrombotic complications or both. The mean follow-up period was 45 months. Secondary patency rates on an intention-to-treat basis (attempted thrombolysis) were 32% and 19% at 1 and 5 years, respectively. After successful CDT, the 1-year secondary patency rate was comparable in LEABs with or without residual lesions (42% versus 45%). Overall, the limb salvage rates were 73% and 55% at 1 and 5 years, respectively. The survival rate was 56% at 5 years. Ten of the 54 LEABs (19%) that eventually failed after successful CDT had three or more reocclusive episodes. Seven LEABs (8.3%) salvaged with CDT eventually became infected from recurrent interventions; six of these necessitated major amputation. Twenty LEABs initially salvaged with CDT were replaced (four immediately and 16 after episodes of recurrent ischemia). Two patients died during hospitalization for treatment of recurrent ischemia.

CONCLUSION

Despite relatively high initial technical success for LEAB thrombolysis, eventual failure is the rule rather than the exception. Recurrent LEAB occlusions lead to significant morbidity, including recurrent interventions, eventual graft infection/replacement, and limb loss. However, LEAB replacement has substantial problems associated with limited conduit, reoperative anatomy, and subsequent wound complications. We therefore advocate an initial attempt at CDT with liberal use of graft replacement for early and late failures or as an initial strategy in those with favorable remaining conduit.

Redo bypass surgery to the infrapopliteal arteries for critical leg ischaemia

OBJECTIVES

to evaluate the results of redo bypass surgery to the infrapopliteal artery and the value of adjuvant arteriovenous fistula (AVF) in this setting.

DESIGN

retrospective study.

MATERIALS

fifty-one redo reconstructions to the infrapopliteal arteries were done for critical leg ischaemia in 45 patients who have had primary infrainguinal reconstructions to the popliteal artery in 20 cases (39%), the crural arteries in 18 (35%), and the pedal arteries in 13 (25%).

METHODS

a PTFE prosthesis was used in 21 cases (41%). A Miller cuff was used in 16 prosthetic grafts. Adjuvant AVF was added to three autogenous vein and 12 prosthetic grafts.

RESULTS

at 2 years, the primary patency rate was 42%, the secondary patency was 43%, the limb salvage was 67%, the survival was 77%, and 53% of patients were alive with salvaged leg. The primary patency rate with a vein graft was 44% at 1 year, with prosthesis plus AVF 67%, but with prosthesis without AVF only 19%. Secondary patency rates were similar. Prosthetic graft with AVF and those without AVF achieved a 1-year leg salvage rate of 100% and 51%, respectively (p =0.01). Patients with adjuvant AVF had a worse 2-year survival rate that those without AVF (31% vs 89%) (p =0.007; RR: 8.87, CI 95%: 1.62-48.42).

CONCLUSIONS

redo bypass surgery using autogenous vein graft may achieve satisfactory long-term results. The use of adjuvant AVF may improve patency of redo infrapopliteal prosthetic bypass grafts.