Vascular surgical society of great britain and ireland: review of 94 tibial bypasses for intermittent claudication

Abstract

BACKGROUND: The management of intermittent claudication is usually non-operative. Most surgeons accept, however, that intervention may be warranted for those with debilitating symptoms. Such interventions are limited to above-knee bypass or balloon angioplasty. However, the authors have performed almost 4500 bypasses for limb salvage, with careful audit of results, and suggest that, in very carefully selected cases, tibial bypass can also be performed for intermittent claudication. The present study aimed to review the results of infrainguinal bypass in this unit; to compare the results for above-knee, below-knee popliteal and tibial bypass in claudicants using either in situ or excised vein as the conduit; and to examine the indications and long-term follow-up for those undergoing tibial bypass for claudication. METHODS: A database has been maintained prospectively in this unit since 1986. Details of all patients undergoing infrainguinal bypass for claudication were retrieved. In-hospital charts were also reviewed and cross-referenced with the computer database. In addition to demographic details, data were extracted on operative indication and procedure, postoperative complications, return to desired level of activity and long-term graft patency. RESULTS: From 1987 to 1997, 409 infrainguinal reconstructions were performed for intermittent claudication (9 per cent of all infrainguinal reconstructions). Of these 73 per cent were in men and 27 per cent in women with a mean age of 64 (range 24-91) years. The operative procedures comprised 165 above-knee popliteal grafts, 150 bypasses to the below-knee popliteal artery and 94 to tibial arteries. There were no operative deaths. However, one of 165 patients who had an above-knee popliteal graft underwent an amputation. Primary and secondary patency rates at 4 years were 62 and 64 per cent for above-knee popliteal bypass, 77 and 81 per cent for below-knee popliteal bypass, and 86 and 90 per cent for tibial bypass. Cumulative survival was 93 per cent at 4 years. CONCLUSION: Tibial bypass for severely disabling claudication can be performed with minimal morbidity and mortality rates, and is at least as durable as more commonly performed bypasses. These data indicate that concern over limb loss, death and limited life span may be exaggerated.