Analysis of dorsalis pedis bypass in the endovascular era

Our institution previously reported excellent short- and long-term outcomes after dorsalis pedis bypass (DPB) for ischemic limb salvage; however, since then, percutaneous transluminal angioplasty with or without stenting (PTA/S) has become the more common management approach. This study aims to describe our nearly 20-year experience with DPB to compare the short- and long-term outcomes between these two revascularization strategies in patients with chronic limb-threatening ischemia.

All patients undergoing DPB or tibial PTA/S between 2000 and 2022 at our institution were retrospectively reviewed. Primary outcomes included perioperative complications, complete wound healing, reintervention, major amputation, major adverse limb events, and a composite variable of major amputation or death (amputation/death). For a more direct comparison, analyses were restricted to procedures performed for chronic limb-threatening ischemia and after the introduction of PTA/S (2005) and to PTA/S patients that were suitable candidates for bypass, had Trans-Atlantic Inter-Society Consensus C or D disease, and a potential DPB target on angiography. Outcomes were evaluated using χ², Kaplan-Meier, and Cox regression analyses.

Between 2000 and 2010, 462 DPB and 395 tibial PTA/S were performed; between 2011 and 2022, 101 DPB and 955 tibial PTA/S were performed. Of those, 259 DPB and 329 tibial PTA/S fit our criteria. Compared with tibial PTA/S patients, DPB patients were similar in age (69.9 years vs 70.8 years) yet were more often White (76% vs 64%) and male (73% vs 52%), and more commonly presented with tissue loss (91% vs 84%) (all P < .05). There were no differences in perioperative complications, including mortality (1.9% vs 3.9%), myocardial infarction (1.9% vs 2.1%), or acute kidney injury (5.8% vs 10%) (all P > .05). Between DPB and PTA/S, despite a trend toward higher rates of complete wound healing after DPB (6-month rate: 43% vs 32%; P = .07), no long-term outcome differences were seen, including reintervention (5-year rate: 41% vs 40%), major amputation (25% vs 24%), major adverse limb events (42% vs 40%), or amputation/death (59% vs 66%) (all P > .05). A sensitivity analysis comparing DPB with single-segment great saphenous vein (ssGSV; n = 213) vs tibial PTA/S demonstrated that DPB had higher rates of complete wound healing (6-month rate: 46% vs 32%; P = .03) and lower rates of amputation/death (5-year rate: 57% vs 66%; P = .04), both of which remained significant after Cox regression (hazard ratio [HR], 1.55 [95% confidence interval, 1.03-2.34] and HR, 0.73 [95% CI, 0.54-0.97], respectively). Conversely, non-ssGSV DPB (n = 47), compared with tibial PTA/S, were approximately 50% more likely to experience loss of patency (HR, 0.49; 95% CI, 0.25-0.98).

Although becoming less common, DPB still provides a durable repair, results in similar perioperative complications compared with tibial PTA/S, and, when performed with ssGSV, may result in higher rates wound healing and lower rates amputation or death. Ultimately, despite the notable decrease in DPB in the endovascular era, these data demonstrate the importance of both revascularization strategies in treating distal arterial disease.