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Prior Endovascular Failure Patterns Identify a High-Risk Phenotype for Infrainguinal Bypass in Chronic
Sahar Ali1, Ahmed M Rashed1, Ahmed Hassan1
1Department of Vascular Surgery, Assiut University, Assiut, Egypt.
Insights
Infrainguinal bypass after failed percutaneous transluminal angioplasty (PTA) in chronic limb-threatening ischemia (CLTI) patients is linked to worse outcomes. Understanding endovascular failure patterns aids in planning CLTI revascularization strategies.
Area of Science:
- Vascular Surgery
- Endovascular Therapy
- Limb Salvage
Background:
- Infrainguinal bypass is a critical revascularization strategy for chronic limb-threatening ischemia (CLTI).
- Prior studies often aggregate diverse endovascular failure types, limiting nuanced understanding of outcomes.
- Differentiating outcomes based on the pattern of endovascular failure is essential for optimizing CLTI management.
Purpose of the Study:
- To compare outcomes of infrainguinal bypass in CLTI patients based on prior endovascular intervention history.
- To analyze differences between primary bypass, bypass after failed percutaneous transluminal angioplasty (PTA), and bypass after restenosis/reocclusion.
Main Methods:
- Retrospective analysis of 235 CLTI patients undergoing infrainguinal bypass (2020-2025).
- Patients categorized into: primary bypass, post-failed PTA bypass, and post-restenosis/reocclusion bypass.
- Primary outcome: amputation-free survival (AFS); secondary outcomes: limb patency, major adverse limb events (MALE).
Main Results:
- Bypass after failed PTA had higher MALE rates (30.8%) compared to primary bypass (14.0%) and post-restenosis/reocclusion (22.9%).
- Two-year AFS was significantly lower after failed PTA bypass (47.7%) versus primary (68.0%) and post-restenosis/reocclusion (58.6%).
- Failed PTA and high conduit risk independently predicted worse AFS on multivariable analysis.
Conclusions:
- Infrainguinal bypass following failed PTA is associated with poorer amputation-free survival in CLTI patients.
- These findings suggest that the pattern of endovascular failure may serve as a prognostic indicator for CLTI revascularization planning.
- While unmeasured confounding exists, the results highlight the importance of considering prior endovascular intervention history in surgical decision-making.
Background:
Prior studies evaluating infrainguinal bypass after failed endovascular therapy often group all failures together. This study compared outcomes after infrainguinal bypass for chronic limb-threatening ischemia (CLTI) among patients undergoing primary bypass, bypass after failed PTA, and bypass after restenosis/reocclusion following initially successful endovascular therapy.
Methods:
This retrospective study included CLTI patients undergoing infrainguinal bypass at a tertiary university hospital between 2020 and 2025. Patients were divided into 3 groups: primary bypass, bypass after failed PTA, and bypass after restenosis/reocclusion. The primary outcome was amputation-free survival (AFS). Secondary outcomes included limb-based patency and major adverse limb events (MALE). Kaplan-Meier analysis and multivariable Cox regression were performed.
Results:
A total of 235 patients were included: 100 primary bypass, 65 bypass after failed PTA, and 70 bypass after restenosis/reocclusion. MALE was more frequent after failed PTA than after primary bypass or restenosis/reocclusion (30.8% vs. 14.0% and 22.9%; P = 0.03). Two-year AFS was 68.0%, 47.7%, and 58.6%, respectively. On Cox regression, bypass after failed PTA (P = 0.009) and high conduit risk (P = 0.022) independently predicted loss of AFS.
Conclusion:
Bypass after failed PTA was independently associated with poorer AFS after multivariable adjustment for age, chronic kidney disease, frailty, WIfI stage 3-4, and conduit risk (HR, 1.88; 95% CI, 1.17-3.03; P = 0.009). These groups differed substantially at baseline, and unmeasured confounding by indication and anatomical complexity cannot be excluded; the observed differences most likely reflect a higher-risk clinical phenotype rather than a causal effect of the prior endovascular attempt. Endovascular failure pattern may therefore be a useful prognostic marker when planning CLTI revascularization.
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