Midterm Outcomes and Predictors of Failure of Lower Extremity Bypass to Para-Malleolar and Pedal Targets

Area of Science:

• Vascular Surgery
• Limb Salvage Surgery
• Critical Limb Ischemia Treatment

Background:

• Distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has seen a significant decline in utilization.
• Analysis of contemporary outcomes and failure factors for LEB to para-malleolar and pedal targets is crucial.

Purpose of the Study:

• To analyze contemporary outcomes of LEB to para-malleolar and pedal targets.
• To identify factors associated with graft failure in these distal bypass procedures.

Main Methods:

• Utilized the Vascular Quality Initiative infrainguinal database (2003-2021).
• Identified LEB procedures to para-malleolar or pedal/plantar targets.
• Assessed primary outcomes: graft patency, major adverse limb events (MALE), and amputation-free survival at 2 years.

Main Results:

• LEB to distal targets decreased from 13.37% to 3.51% of all LEB procedures (2003-2021).
• Two-year outcomes: 50.56% primary patency, 63.49% MALE, 71.71% amputation-free survival.
• Non-great saphenous vein conduits and low center volume were associated with worse outcomes; high center volume improved patency and reduced MALE.

Conclusions:

• Open surgical bypass to distal targets remains a viable option for IP-CLTI.
• High-volume centers are associated with better graft patency and limb salvage rates.
• Optimizing graft patency and limb salvage requires performing distal bypasses at high-volume centers.