Repeat leg bypass after multiple prior bypass failures

The optimal treatment of patients with severe lower extremity ischemia after multiple failed prior bypasses is unclear. It is presently unknown whether failure of attempted revascularization in these patients is so likely that such operation should not be elected. We have maintained an aggressive surgical policy of repeated revascularization regardless of prior failures. A review of our clinical experience with this difficult patient group was performed to determine the results of this policy.

From 1980 to 1992, 85 revascularization procedures were performed in 81 patients with lower extremity ischemia after failure of two or more prior infrainguinal bypasses in the same leg. All patients were prospectively entered and monitored in our vascular registry. Seventy-two operations were the third procedure, six operations were the fourth procedure, and seven operations were the fifth procedure on the same extremity. Twenty-six of the 85 procedures (30%) were revisions of failing grafts discovered by routine surveillance methods, whereas 59 were replacements of thrombosed grafts. Autogenous reconstruction was used in 67 procedures (79%), and prosthetic reconstruction was used in 18 procedures (21%). The distal anastomosis was to the popliteal artery in 19 patients and infrapopliteal artery in 66.

Mean time to failure of the first leg bypass was 24 months and 4.9 months for the second bypass. Detailed hematologic screening revealed identifiable hypercoagulable disorders in nine (15%) of 59 patients screened after 1987. All nine had anticardiolipin antibodies. The operative mortality rate was 4%. Mean follow-up after the most recent operation was 17 months. The primary patency rate at 4 years was 79.8%. The limb salvage rate was 69.6% at 4 years.

These results indicate that limb revascularization after two or more failed leg bypasses results in low operative mortality rates and surprisingly good primary patency and limb salvage rates at 4 years. The patient survival rate through 4 years is unexpectedly high. In our opinion these results justify an aggressive policy of limb vascularization after multiple failed prior bypasses.