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Femorotibial bypass for claudication: do results justify an aggressive approach?
M S Conte1, M Belkin, M C Donaldson
1Division of Vascular Surgery, Brigham & Women's Hospital, Boston, MA 02115, USA.
Insights
Femorotibial bypass surgery for disabling claudication offers durable results in select patients. This infrainguinal arterial reconstructive surgery provides improved walking distance and high patient satisfaction.
Area of Science:
- Vascular Surgery
- Reconstructive Surgery
- Peripheral Artery Disease
Background:
- Infrainguinal arterial reconstructive surgery for claudication remains controversial.
- Femorotibial bypass is an aggressive approach for disabling claudication.
Purpose of the Study:
- To review outcomes of femorotibial bypass for disabling claudication.
- To define the role of this surgical approach in select patients.
Main Methods:
- Retrieved data from vascular registry and hospital records (16-year period).
- Included patients undergoing femorotibial reconstruction for disabling claudication.
- Conducted follow-up interviews to assess outcomes and patient satisfaction.
Main Results:
- 57 femorotibial reconstructions in 53 patients; 5% of infrainguinal vein reconstructions.
- 5-year survival: 54% ± 15%; primary patency: 81% ± 6%; secondary patency: 86% ± 5%.
- No major amputations; improved walking distance and patient satisfaction reported.
Conclusions:
- Femorotibial bypass for claudication yielded superior results compared to limb salvage and equivalent results to femoropopliteal bypass.
- Recommended for low-risk patients with significant impairment, adequate vein conduit, and suitable tibial outflow.
- Offers expectation of durable long-term results for carefully selected patients.
Purpose:
The role of infrainguinal arterial reconstructive surgery for claudication is controversial. We reviewed the results of femorotibial bypass procedures performed in a select group of patients with disabling claudication in an attempt to define a role for this aggressive approach.
Methods:
Data were retrieved from the vascular registry, and hospital records were obtained for all patients undergoing femorotibial reconstruction for disabling claudication during the past 16 years at Brigham and Women's Hospital. Follow-up interviews were obtained to assess overall health, walking impairment, functional status, and patient satisfaction.
Results:
During a 16-year period a total of 57 tibial reconstructions were performed in 53 patients for claudication (5% of all infrainguinal vein reconstructions). Autogenous vein conduit was used in all cases, most of which (70%) involved the greater saphenous vein in situ. Distal anastamoses were to the tibioperoneal trunk (12%), anterior tibial (18%), posterior tibial (47%), and peroneal (23%) arteries. Major complications occurred in 9%, and no perioperative deaths occurred. Overall 5-year survival was 54% +/- 15%, and no major amputations were performed. Cumulative primary and secondary graft patency at 5 years were 81% +/- 6% and 86% +/- 5%, respectively. Patency rates were significantly better than those achieved in a concurrent series of tibial bypasses for limb salvage and were equivalent to those achieved with femoropopliteal bypass for claudication. Interviewed patients reported improved walking distance, reduced claudication, and a high degree of overall satisfaction with their operation.
Conclusion:
Results obtained with femorotibial bypass performed for claudication were superior to those obtained for limb salvage and were equivalent to those obtained with femoropopliteal bypass for claudication. The results obtained in this highly selected cohort suggest that patients at low risk with significant functional impairment from claudication, available autogenous vein, and suitable tibial outflow to the ischemic muscular bed can be offered revascularization with the expectation of durable long-term results.