The benefits of secondary interventions in patients with failing or failed pedal bypass grafts

Autogenous bypass grafts to pedal arteries have successfully salvaged limbs and restored function in patients with critical ischemia. The benefits of secondary interventions to save failing or already failed grafts remains uncertain.

A retrospective analysis was made of consecutive pedal bypasses performed between 1987 and 1998. Patency and limb salvage by life-table analysis and variables affecting outcome were compared with the log-rank test.

Two hundred thirteen patients, 144 males, 69 females (mean age 68 years, range 30 to 91) underwent pedal bypass grafting in 228 limbs using autogenous vein grafts (nonreversed saphenous vein, n = 190; reversed, n = 15; composite, n = 23). One-hundred fifty-seven patients were diabetic, 34 had renal insufficiency (serum creatinine >2.0), and 14 were on dialysis. Gangrene or ulceration were present in 224 patients, rest pain in 24. Cumulative primary and secondary patency rates were 57% and 67% at 5 years. Limb salvage was 78% at 5 years. Secondary interventions in 46 patients included patch angioplasty/surgical revision (n = 28), thrombectomy (n = 15), thrombolysis (n = 11), and balloon angioplasty (n = 6). Patency in 19 of 26 (73%) failed grafts and in 19 of 20 (95%) failing grafts could be restored initially. Cumulative 2-year patency and limb salvage rates following reinterventions were 36% and 58%, respectively. Patency rates and limb salvage for failed grafts (7%, 44%) were significantly worse than those for failing grafts (81%, 77%; P <0.0001, P <0.05, respectively). All patients with renal insufficiency who underwent reinterventions for failed or failing grafts required major amputation within 1 year (P <0.0001 versus those without renal insufficiency).

Autogenous pedal bypass grafts are durable operations with excellent long-term patency and limb salvage rates. Revision of failing grafts has been effective using both endovascular and surgical techniques. Failed grafts have poor long-term patency and moderate limb salvage rates, and our data do not justify secondary procedures to attempt to save failed grafts in patients with renal insufficiency.