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Multilevel bypass grafting: is it worth it?
Alistair Sharples1, Mark Kay1, Timothy Sykes1
1Department of Vascular Surgery, Shrewsbury and Telford NHS Trust, Shrewsbury, UK.
Insights
Simultaneous multilevel bypass grafts for extensive arterial disease offer good long-term outcomes and acceptable mortality in high-risk patients. This approach provides significant benefits for severe critical limb ischemia and tissue loss.
Area of Science:
- Vascular Surgery
- Cardiovascular Medicine
- Surgical Outcomes
Background:
- Multilevel arterial disease traditionally treated with inflow procedures alone.
- Simultaneous multilevel bypass grafts attempted but considered high-risk.
- This study reports a single-center experience with multilevel bypass grafts over 15 years.
Purpose of the Study:
- To evaluate the safety and efficacy of simultaneous multilevel bypass grafts.
- To assess outcomes in patients with extensive aortoiliac and infrainguinal disease.
- To determine the benefits of primary multilevel grafting in high-risk patients.
Main Methods:
- Retrospective review of patients undergoing simultaneous aortoiliac and infrainguinal bypasses.
- Data collected from January 1996 to January 2011 at a single district general hospital.
- Analysis of surgical indications, reconstruction methods, mortality, morbidity, and long-term outcomes.
Main Results:
- 32 multilevel procedures performed for acute ischemia, critical ischemia, tissue loss, or claudication.
- High inflow reconstruction rates (71.9% direct, 28.1% extra-anatomic).
- Low 30-day mortality (6.3%), high survival to discharge (90.6%), and 1-year survival (87.5%).
- Excellent limb salvage rates: 96.9% at 30 days, 85.7% at 1 year, 75.9% at 5 years.
- 12 patients (37.5%) required re-interventions.
Conclusions:
- Multilevel bypass procedures yield good long-term outcomes and acceptable mortality in high-risk patients.
- Significant benefits observed for primary multilevel grafting in severe critical limb ischemia with tissue loss.
- This approach is a viable option for complex arterial disease involving multiple levels.
Background:
Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years.
Methods:
We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital.
Results:
There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures.
Conclusions:
Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.
