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Published on: September 22, 2020
Mid-term clinical outcome of critical limb ischemia after infrapopliteal bypass surgery
Jin Okazaki1, Atsushi Guntani, Kenichi Homma
1Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. jokazaki@surg2.med.kyushu-u.ac.jp
Insights
Infrapopliteal bypass surgery using autologous vein grafts is effective for critical limb ischemia, offering good patency and limb salvage. However, patients with end-stage renal disease on hemodialysis face poorer survival outcomes.
Area of Science:
- Vascular Surgery
- Arterial Reconstruction
- Critical Limb Ischemia Management
Background:
- Peripheral arterial occlusive disease affecting the infrapopliteal segment necessitates bypass surgery for limb salvage.
- Autogenous vein conduits are considered the gold standard for infrapopliteal bypass.
- Current practices exhibit heterogeneity in surgical strategies, techniques, and outcomes.
Purpose of the Study:
- To review a 7-year experience with infrapopliteal bypass surgery.
- To analyze early and mid-term clinical outcomes of these procedures.
- To evaluate the impact of end-stage renal disease on outcomes.
Main Methods:
- A retrospective review of 63 infrapopliteal bypasses performed between May 2003 and May 2010.
- Graft types included autologous vein (great saphenous vein, lesser saphenous vein) and composite grafts.
- Patient outcomes were assessed for patency, amputation-free survival, and overall survival, with subgroup analysis for hemodialysis patients.
Main Results:
- Autologous vein grafts were used in 57 of 63 bypasses.
- No 30-day mortality was observed; 3.5% in-hospital mortality.
- 1-year primary patency was 73.7%, secondary patency 82.4%, amputation-free survival 84.7%, and overall survival 88.1%.
- 3-year outcomes showed primary patency of 65.4%, secondary patency 76.3%, amputation-free survival 71.0%, and overall survival 74.6%.
- Patients on hemodialysis had significantly worse 3-year secondary patency, amputation-free survival, and overall survival compared to non-hemodialysis patients.
Conclusions:
- Infrapopliteal arterial bypass is a safe and effective procedure for critical limb ischemia, yielding favorable mid-term results.
- Excellent mid-term graft patency and amputation-free survival were achieved.
- Renal insufficiency, particularly end-stage renal disease requiring hemodialysis, is associated with poorer limb salvage and long-term survival rates.
Objective:
Critical limb ischemia caused by peripheral arterial occlusive disease of the infrapopliteal segment is best managed by bypass surgery with an autogenous vein conduit. Yet there remains confusing heterogeneity in the strategy, utilization, techniques, and outcomes in current practice. We reviewed our 7-year experience of infrapopliteal bypass surgery to analyze early and mid-term clinical outcomes.
Methods:
From May 2003 through May 2010, 63 bypasses to the infrapopliteal artery were performed in 59 patients. This comprised 32.4% of the 194 infrainguinal arterial reconstructions performed during that period.
Results:
Of the 63 bypasses, 57 were performed with an autologous vein and 6 with a composite graft. For the autologous vein bypasses, a single-segment great saphenous vein (GSV) was used in 39 bypasses, which included 23 reversed, 5 in situ, and 11 non-reversed free grafts. "Spliced" vein grafts, constructed by splicing the GSV or lesser saphenous veins (LSV) together, were utilized in 18 bypasses. No deaths occurred within 30 days of surgery. Two patients (3.5%) died while hospitalized . Five grafts failed within 30 days of surgery due to thrombosis or bleeding. The primary graft patency, secondary graft patency, amputation-free survival (AFS) and overall survival were 73.7%, 82.4%, 84.7%, 88.1%, respectively at 1 year and 65.4%, 76.3%, 71.0%, 74.6% at 3 years. When patients were divided into groups based on the presence of end-stage renal disease on hemodialysis (HD), the 3-year secondary patency, AFS, and overall survival were 82.5%, 49.2, 49.2% in the HD group and 74.1%, 84.2%, 88.8% in the non-HD group. The overall survival in the HD group was significantly worse compared with the non-HD group.
Conclusion:
Infrapopliteal arterial bypass is a safe, durable and highly effective procedure in patients with CLI, with excellent mid-term patency and amputation-free survival. Renal insufficiency may be associated with a poorer limb salvage rate and long-term survival.
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