Abstract
AimOn the basis of the CRITISCH registry outcomes in patients with critical limb ischemia (CLI) undergoing lower extremity bypass surgery were analyzed according to the site of distal anastomosis and type of bypass material.Patients and methodsA total of 284 patients with lower extremity bypasses consisting of 75 patients with bypasses above the knee (group 1), 80 with bypasses below the knee (group 2) and 129 crural or pedal bypasses (group 3) were included in the study. Altogether, 159 autologous saphenous vein grafts and 125 synthetic grafts were used.ResultsThere were no perioperative complications in 191 out of the 284 patients (67.3 %) and 236 of the 284 patients (83.1 %) had open bypasses at hospital discharge. An uneventful postoperative course was observed in 76 % of the patients in group 1, 62.5 % in group 2 and 65.1 % in group 3. Amputation-free survival was 86 % at 1 year in group 1, 65 % in group 2 and 69 % in group 3. For bypasses above the knee synthetic grafts were at least not inferior to vein grafts (amputation-free survival at 1 year: prosthetic bypasses 92 % and saphenous vein grafts 71 %, p = 0.147), whereas in the crural/pedal bypass group vein grafts showed better amputation-free survival at 1 year (76 %) compared with synthetic bypasses (56 %, p = 0.105). Patients with a PREVENT III (PIII) CLI risk score ≤3 exhibited better amputation-free survival at 1 year (78 %) compared to patients with a PIII CLI risk score of 4–7 (69 %, p = 0.053). The same applied to patients with Rutherford class 4 vs. Rutherford class 6 CLI.ConclusionIn patients with CLI and above-knee bypasses, vein grafts confer no benefits compared with synthetic grafts for at least 1 year follow-up; however, in the case of more distal anastomoses vein grafts should be preferred.
Highlights
Supported by the German Institute for Vascular Healthcare Research (Deutsches Institut für Gefäßmedizinische Gesundheitsforschung, DIGG) of the German Society for Vascular Surgery and Vascular Medicine (Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin, DGG)
The present study examined the results of peripheral bypass surgery according to (a) the site of distal anastomosis and (b) the type of bypass material by analyzing the data of the CRITISCH registry [3, 4]
A diagnosis of critical limb ischemia (CLI) symptoms of more than 2 weeks standing was the criterion for inclusion in the CRITISCH registry and CLI was defined as peripheral arterial occlusive disease and an ankle/brachial index of ≤ 0.4 and/or residual pain (Rutherford class 4 or Fontaine stage III) and/or trophic disorders or necrosis/gangrene in the lower extremities
Summary
The methodology of the CRITISCH study has been described elsewhere [3, 4]. A diagnosis of CLI symptoms of more than 2 weeks standing was the criterion for inclusion in the CRITISCH registry and CLI was defined as peripheral arterial occlusive disease and an ankle/brachial index of ≤ 0.4 and/or residual pain (Rutherford class 4 or Fontaine stage III) and/or trophic disorders or necrosis/gangrene in the lower extremities 2. Major adverse limb event (MALE) in the index extremity at 1 and 2 years, such as amputation above the ankle or major intervention (new bypass, bypass revision (jump/interposition) or thrombectomy/thrombolysis). 4. Sustained clinical improvement at 2 years: upward shift on the Rutherford or Fontaine classification to the level of intermittent claudication in amputation-free surviving patients not requiring (primary improvement) or following (secondary improvement) repeat target lesion revascularization. 6. Any reintervention, amputation above the ankle in the index limb or stenosis/occlusion at 2 years. Analysis between patients with and without complications was performed with respect to the effect of the various prospectively recorded risk factors. Complications included the parameters wound infection, lymphatic fistula, compartment syndrome, acute coronary event, stroke/ transient ischemic attack (TIA) and major amputation. Differences with p-values
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