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Fate of the contralateral leg after infrainguinal bypass
W C Tarry1, D B Walsh, N J Birkmeyer
1Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Insights
Diabetes, coronary artery disease, low ankle-brachial index, and younger age predict the need for future vascular intervention in the contralateral leg after infrainguinal bypass. These factors are additive in predicting intervention likelihood.
Area of Science:
- Vascular Surgery
- Cardiovascular Disease
- Diabetology
Background:
- Infrainguinal bypass is a critical intervention for peripheral artery disease.
- Predicting future vascular needs in the contralateral limb is essential for comprehensive patient management.
- Understanding risk factors aids in proactive limb salvage strategies.
Purpose of the Study:
- To identify variables predicting the need for future vascular intervention in the contralateral leg.
- To analyze risk factors associated with interventions in the previously untreated contralateral limb following infrainguinal bypass.
Main Methods:
- Retrospective review of 383 patients undergoing infrainguinal bypass for occlusive disease.
- Exclusion of patients with immediate contralateral limb-threatening ischemia or staged procedures.
- Life-table and regression analysis to examine contralateral leg outcomes over a mean follow-up of 38 months.
Main Results:
- Twenty percent of patients required contralateral intervention within the follow-up period.
- Key predictors identified: diabetes (RR 2.4x), coronary artery disease (RR 1.8x), low ankle-brachial index < 0.7 (RR 2.1x), and age < 70 years (RR 2.2x).
- Risk factors were additive, with prediction accuracy increasing significantly when multiple factors were present.
Conclusions:
- Diabetes, coronary artery disease, contralateral ankle-brachial index, and younger age are significant predictors of future contralateral leg intervention.
- These risk factors have an additive effect, enabling better prediction of intervention needs.
- Identifying high-risk patients allows for targeted follow-up and planning for future limb salvage procedures.
Purpose:
To identify variables predictive of the need for future vascular intervention in a leg contralateral to one currently undergoing infrainguinal bypass.
Methods:
We reviewed the records of 450 consecutively treated patients undergoing infrainguinal bypass for occlusive disease to examine the outcome of a previously untreated contralateral leg. Patients with coexistent contralateral limb-threatening ischemia at the time of initial ipsilateral operation were excluded, as were patients with bilateral disease who underwent a staged contralateral procedure within 3 months of the ipsilateral operation. This yielded a study cohort of 383 patients with no anticipated intervention in the contralateral leg who were followed for a mean value of 38 months. Patient survival and subsequent intervention in the contralateral leg were examined with life-table and regression analysis.
Results:
Mean age of the patients was 68 years; 60% were men; 54% had diabetes; and 50% had coronary artery disease. The initial ipsilateral operation was performed for limb threat in 90% of instances. Twenty percent of patients subsequently needed intervention in the contralateral leg (infrainguinal bypass 83%, primary major amputation 17%). According to life-table analysis, 30% of patients needed intervention at 5 years, and the overall survival rate was 51% at 5 years. Multivariate analysis indicated that the need for future contralateral intervention was independently predicted with the following four risk factors: diabetes (relative risk [RR] 2.4x), coronary artery disease (RR 1.8x), lower initial ankle-brachial index (RR 2.1x with ankle-brachial index less than 0.7), and younger age (RR 2.2x if age less than 70 years). Regression models predicted the need for contralateral intervention for only 8% of patients at 5 years when none of these risk factors was present but for 67% when all risk factors were present.
Conclusion:
The fate of the contralateral leg after infrainguinal bypass is affected by diabetes, coronary artery disease, contralateral ankle-brachial index, and age at initial ipsilateral bypass. The effect of these risk factors is additive in prediction of the likelihood of future intervention. Knowledge of these factors may help identify instances in which the contralateral greater saphenous vein will be important for future limb salvage and also determine which patients need more careful follow-up care.