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Limits of infrapopliteal bypass surgery for critical leg ischemia: when not to reconstruct
F Biancari1, I Kantonen, A Albäck
1Division of Vascular Surgery, Helsinki University Central Hospital, PO Box 340, 00029 HYKS, Helsinki, Finland.
Insights
Identifying risk factors for infrapopliteal bypass surgery outcomes is crucial. High C-reactive protein, dialysis, and prior cardiac/stroke events predict poor results, emphasizing surgical experience and patient selection for critical leg ischemia revascularization.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Critical Care
Background:
- Critical leg ischemia (CLI) poses significant risks, necessitating revascularization procedures like infrapopliteal bypass grafts.
- Understanding risk factors is vital for optimizing patient outcomes and surgical decision-making in CLI treatment.
Purpose of the Study:
- To identify key risk factors influencing the immediate 30-day postoperative outcomes of infrapopliteal bypass grafts.
- To evaluate the impact of patient comorbidities and inflammatory markers on graft patency, leg salvage, and survival rates.
Main Methods:
- Retrospective analysis of 511 infrapopliteal bypass procedures in 439 patients with CLI.
- Assessment of patient history (myocardial infarction, angina, stroke), C-reactive protein levels, dialysis status, and surgical experience.
- Evaluation of 30-day postoperative outcomes including primary/secondary patency, leg salvage, survival, and composite endpoints.
Main Results:
- 30-day outcomes included 77.5% primary patency, 83.4% secondary patency, 89.8% leg salvage, and 94.7% survival.
- History of myocardial infarction, angina, or stroke significantly impacted cardiac and cerebrovascular complications.
- Elevated C-reactive protein predicted longer hospital stay, cardiac complications, and poorer leg salvage. Long-term dialysis was associated with adverse outcomes. Surgical experience positively influenced leg salvage.
Conclusions:
- Infrapopliteal bypass is a complex procedure demanding significant surgical expertise.
- Contraindications include severe coronary disease, prior stroke, renal failure on dialysis, diabetes, and high C-reactive protein, as these patients face elevated risks of early postoperative complications and mortality.
Abstract:
The aim of this study was to identify the risk factors affecting the immediate 30-day postoperative outcome of infrapopliteal bypass grafts. A series of 511 revascularization procedures to the infrapopliteal arteries have been performed in 439 patients with critical leg ischemia. There were 306 crural bypasses and 205 pedal bypasses. The 30-day postoperative primary and secondary patency rates were 77.5% and 83.4%, respectively; the leg salvage rate was 89.8%; the survival rate was 94.7%; and 85.1% of patients were alive with a salvaged leg. A history of myocardial infarction, angina pectoris, or stroke had a great impact on the postoperative cardiac and cerebrovascular fatal and nonfatal complications. C-reactive protein arose as an important predictor of the length of hospital stay (p = 0.03), postoperative cardiac complications (p = 0.02), leg salvage (p = 0.009), amputation with patent graft (p = 0.009), and patients who survived with a salvaged leg (p = 0.006). Poor results were achieved in patients on long-term dialysis. Surgical experience had an influence on leg salvage (p = 0.02) and on patients alive with salvaged leg rates (p = 0.009). Infrapopliteal bypass surgery is a demanding procedure requiring high surgical skill and experience. Revascularization may be contraindicated when severe coronary disease, previous stroke, renal failure requiring long-term dialysis, diabetes, or high serum concentration of C-reactive protein coexist with critical leg ischemia, as these patients are at high risk for early postoperative leg or life loss.