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Published on: November 24, 2014
Natural history of composite sequential bypass: ten years' experience
W F Oppat1, W H Pearce, W D McMillan
1Department of Surgery, Northwestern University Medical School, Chicago, Ill, USA.
Insights
Composite sequential bypass (CSB) offers moderate 2-year patency for limb salvage. However, graft patency and limb salvage rates significantly decline after 2 years, with most patients requiring amputation within a year of graft failure.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Limb Salvage Procedures
Background:
- Previous reports indicated 48-month patency rates for composite sequential bypass (CSB) approaching 60%.
- Extended long-term patency and limb salvage rates following CSB remained unknown.
Purpose of the Study:
- To determine the long-term patency and limb salvage rates of composite sequential bypass (CSB).
- To investigate the influence of sex, bypass configuration, and warfarin therapy on CSB outcomes.
Main Methods:
- Retrospective review of medical records for 100 consecutive patients undergoing 102 CSBs over a 10-year period (1986-1996).
- Analysis included comparison of primary patency and limb salvage rates based on patient demographics, bypass details, and anticoagulation therapy (warfarin vs. aspirin).
Main Results:
- Primary patency rates were 56% at 24 months, declining to 29% at 48 months and 20% at 84 months.
- Limb salvage rates were 64% at 24 months, decreasing to 30% at 48 months and 23% at 84 months.
- A significant proportion of patients (66% by 3 months, 90% by 1 year) experienced graft failure requiring amputation.
Conclusions:
- Composite sequential bypass provides reasonable patency for limb salvage up to 2 years.
- Patency rates demonstrate a steady decline between years 2 and 5.
- Limb salvage outcomes are poor following CSB failure, with a high rate of subsequent amputation within one year.
Background:
We previously reported 48-month patency rates of composite sequential bypass (CSB) approaching 60%. Yet, extended patency and limb salvage rates are unknown.
Hypothesis:
Long-term patency and limb salvage rates of CSB are affected by sex, bypass configuration, and warfarin therapy.
Design:
Medical records of all patients who underwent CSB during a 10-year period were retrospectively reviewed.
Setting:
A referral center for the Chicago, Ill, region.
Patients:
One hundred consecutive patients (mean age, 68.8 years; 57% were men and 49% had diabetes) undergoing 102 CSBs for limb salvage (ulcer, 43%; rest pain, 39%; and gangrene, 18%) from January 1986 to January 1996 were identified.
Interventions:
Warfarin was used after surgery by 72% of patients and aspirin was used by the remainder of them.
Main Outcome Measures:
Life table primary patency and limb salvage rates were compared for sex, diabetes mellitus status, location of distal prosthetic anastomosis (above knee vs. below knee), and anticoagulation drug therapy (warfarin sodium vs aspirin) with log-rank statistics.
Results:
Primary patency of CSB was 56% at 24 months, 29% at 48 months, and 20% at 84 months (SE <10%; mean follow-up, 19.6 months [range, 1.0-110.0 months]). Limb salvage rates were 64% at 24 months, 30% at 48 months, and 23% at 84 months (SE <10%); 66% and 90% of patients had failed grafts requiring amputation by 3 months and 1 year, respectively.
Conclusions:
Composite sequential bypass for limb salvage provides reasonable 2-year patency. However, patency rates steadily declined from year 2 to year 5. After CSB failure, limb salvage rates are poor, with 90% of patients progressing to amputation within 1 year.
