Bypass For Critical Limb Ischemia Research Articles

Ten-year experience with use of cryopreserved allografts for redo infrapopliteal bypass.

The aim of this study is to report the early and late outcomes of cryopreserved saphenous vein (CSV) in redo infrainguinal bypass and to investigate possible predictors of primary patency loss. All patients who underwent a redo bypass for critical limb ischemia from January 2010 to December 2020 were reviewed. Early and late complications were analyzed and included. The endpoints of the study were all cause mortality, major limb amputation, and primary patency (PP). Data were collected from 95 patients. Among the entire cohort, 16 (16.8%) patients received a cryopreserved vessel bypass with anastomosis in the popliteal artery and 79 (83.2%) patients had cryopreserved vessel bypasses with distal anastomosis in tibial vessels. Median duration of follow-up was 73months; during this, period estimated survival at 5years was 80.5 ± 4% (95% CI, 78.0-91.2) and estimates of freedom from limb amputation was 90.3 ± 3.2% (95% CI, 87.3-98.1). Overall, the estimated primary patency of the bypass was 43.7 ± 6.7% (95% CI, 30.2-51.4). On multivariable analysis, intraprocedural tibial vessel angioplasty (HR = 2.3, p = 0.01), distal anastomosis in tibial vessels (HR = 3.6, p = 0.36), and the use of a composite graft (HR = 2.4, p = 0.01) were independently associated with loss of PP. The use of CSV in redo bypass is an effective strategy in salvaging threatened lower extremities and in preventing or delaying limb amputation. Our results confirm that further attempts at revascularization are generally appropriate, even in technically changing patients.

Right axillopopliteal artery bypass using a combined transiliac and lateral popliteal approach for groin infection and lymph fistula.

Wound infection in the groin is a serious complication after vascular bypass surgery. The combined treatment of critical limb ischemia and recurrent infection presents challenges for vascular surgery(1Lounes Y. Ozdemir B. Alric P. Canaud L. Trans-iliac Bypass for Critical Limb Ischaemia with Groin Necrosis: A Case Report.EJVES Short Reports. 2019; 42: 31-33https://doi.org/10.1016/j.ejvssr.2019.01.002Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar, 2Multon S. Jayet J. Javerliat I. Coscas R. Coggia M. Aortic–tibial transiliac wing extra-anatomic bypass with distal fistula for treatment of an infected deep femoral pseudoaneurysm.J Vasc Surg Cases, Innov Tech. 2022; 8: 201https://doi.org/10.1016/j.jvscit.2022.02.008Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 3Engin C, Posacioglu H, Ayik F, Apaydin A . Management of vascular infection in the groin. Texas Hear Inst J (2005) 32:529–534.Google Scholar). In this case, we successfully managed the wound infection in the groin after axillofemoral artery bypass grafting, using a combination of trans-iliac bypass and lateral popliteal approach(4Enzmann F.K. Nierlich P. Eder S. Aspalter M. Dabernig W. Aschacher T. et al.Trans-Iliac Bypass Grafting for Vascular Groin Complications.Eur J Vasc Endovasc Surg. 2019; 58: 930-935https://doi.org/10.1016/j.ejvs.2018.11.003Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Benzing C. Fellmer P. Lateral Approach to the Distal Femoral Artery in Femoro-Anterior-Tibial Bypass Surgery.Eur J Vasc Endovasc Surg. 2016; 52: 267https://doi.org/10.1016/j.ejvs.2016.04.024Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). A 74-year-old man, having Buerger's disease and arteriosclerosis obliterans, presented with extensive lymphatic fistula and necrosis of the groin (Fig.1) after right axillary artery to the right deep femoral artery bypass, which had been patented for last five years after the several revascularizations of iliac arteries and femoral arteries. Due to the several open surgeries, such as aorto-right external iliac artery bypass, aorto-left popliteal artery bypass, cholecystectomy and resection of gastric cancer, we chose right axillopopliteal artery bypass grafting, through the iliac wing. The skin incision was made along the iliac crest and the external oblique muscle fascia was separated to reach the pelvis, and a longitudinal incision was made anterosuperior to the greater trochanter to create a gluteal pathway to bypass the infected groin. 10-mm hole was made by shaving the bone about 4 cm from the iliac crest, and the graft was passed through the hole. (Fig 2). A lateral popliteal approach was selected for revascularization owing to extensive groin and medial thigh infective wounds. After that the extensive lymphatic fistula and necrosis were controlled with using negative pressure wound therapy.Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT) The postoperative course was uneventful, and contrast-enhanced computed tomography confirmed proper arrangement of the graft, without bending (Fig 3 and Fig 4). He was discharged from the hospital on the 14th postoperative day. The computed tomography which was taken one year later showed the patency of this graft. The combination of trans - iliac bypass and lateral popliteal approach was shown to be effective in this case of extensive groin and medial compartment infection, and can potentially be applied in similar future cases.Figure 4View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Black Patients Have Higher Mortality As Compared to Non-black Patients at One-year End Point after Infrainguinal Bypass for Critical Limb Ischemia: A Study From Vqi Database

Black Patients Have Higher Mortality As Compared to Non-black Patients at One-year End Point after Infrainguinal Bypass for Critical Limb Ischemia: A Study From Vqi Database

End-stage renal disease patients undergoing angioplasty and bypass for critical limb ischemia have worse outcomes compared to non-ESRD patients: Systematic review and meta-analysis.

End-stage renal disease (ESRD) is associated with increased morbidity and mortality following lower extremity amputation for critical limb ischemia (CLI). Angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We compared the long-term outcomes in patients with CLI undergoing angioplasty or bypass to evaluate the differences between patients with ESRD and those without ESRD. Established databases were searched for observational studies comparing outcomes following bypass or angioplasty for CLI in patients with ESRD to those in non-ESRD patients. End points included survival, limb salvage, amputation-free survival (AFS), and primary and secondary patency at 1-year post-procedure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random effect model. We included 20 studies with a total of 24,851 patients. ESRD patients compared to non-ESRD patients with CLI had significantly lower survival post-angioplasty (OR 0.51, 95% CI 0.36-0.72, p < .001) and post-bypass (OR 0.26, 95% CI 0.15-0.45, p < .001). ESRD patients had lower rates of limb salvage post-bypass (OR 0.33, 95% CI 0.21-0.53, p < .001) and post-angioplasty (OR 0.54, 95% CI 0.41-0.70, p < .001). AFS was significantly lower in ESRD patients compared to non-ESRD patients following angioplasty (OR 0.48, 95% CI 0.32-0.71, p < .001) and bypass (OR 0.28, 95% CI 0.16-0.47, p < .001) despite no significant differences in primary patency. ESRD patients had overall worse secondary patency post-angioplasty and/or bypass (OR 0.54, 95% CI 0.32-0.94, p=.03) compared to non-ESRD patients. A meta-analysis of four studies directly comparing survival in ESRD patients with CLI based on whether they underwent angioplasty or bypass showed no difference (OR 0.93, 95% CI 0.64-1.35, p=.69). ESRD patients have worse survival, limb salvage, and AFS outcomes following angioplasty and bypass for CLI compared to non-ESRD patients. Large randomized controlled trials comparing these two modalities of treatment in this patient population are needed for further clarity.

Autologous saphenous vein and heparin-bonded expanded polytetrafluoroethylene as graft materials for below-the-knee femoro-popliteal bypass in patients with critical limb ischemia: A propensity score-matched analysis

ObjectiveTo compare the outcomes of heparin bonded expanded polytetrafluoroethylene (HePTFE) and autologous saphenous vein (ASV) in patients undergoing below-knee (BK) femoro-popliteal bypass for critical limb ischemia (CLI). DesignRetrospective single-centre matched case–control study. MethodsFrom 2003 to 2019, 275 consecutive BK bypasses for CLI were performed, 109 with the ASV and 166 with a HePTFE graft. All the baseline characteristics that were reliably measured and were potentially relevant in the decision-making process were included as confounders in a logistic regression model and the factors that were significantly different between the two groups then used to perform a propensity matching analysis. Propensity score-based matching was performed in a 1:1 ratio to compare outcomes. Arterial hypertension, hyperlipemia, the need for tibial anastomosis at the distal level and the run-off status were the covariates included in the matching. Follow-up outcomes were estimated by Kaplan–Meier methods and compared with log rank test. ResultsAfter propensity matching, 101 HePTFE bypasses were matched with 101 ASV bypasses. The median duration of follow-up was 37 months (range 1–192). The 5-year survival rate was 67.5% (standard error (SE) 0.05) in the HePTFe group and 64.5% (SE 0.06) in the ASV group (p = 0.8, log rank 0.04). Primary patency rates were 38% (SE 0.06) in the HePTFE group and 41% (SE 0.06) in the ASV group (p = 0.7, log rank 0.3). Also assisted primary patency and secondary patency rates did not differ in the two groups. Amputation-free survival was 53% (SE 0.05) in the HePTFE group and 58% (SE 0.06) in the ASF group (p = 0.6, log rank 0.2). ConclusionsHePTFE provided 5-year similar results to those obtained with use of the ASV in equivalent patients with CLI undergoing below-knee or tibial bypass.

Modified frailty index as an indicator for outcomes, discharge status, and readmission after lower extremity bypass surgery for critical limb ischemia

Frailty has been associated with poor postoperative outcomes. This study evaluated the 5-factor modified frailty index (mFI-5) to assess complications, mortality, discharge disposition, and readmission in patients undergoing lower extremity (LE) bypass for critical limb ischemia (CLI).The National Surgical Quality Improvement Program vascular module (2011-2017) was utilized to identify patients undergoing LE bypass for CLI. Adverse events included infectious complications, bleeding complications, prolonged ventilation, amputation, readmission, and death. Patients were divided into groups based on mFI-5 scores: mFI1 (0), mFI2 (0.2), mFI3 (0.4), and mFI4 (0.6-1). Data were analyzed using the Cochran-Mantel-Haenszel statistic for general association and multivariable logistic regression. About 11,530 patients undergoing bypass for CLI were identified (42% rest pain and 58% tissue loss; 23% mFI1, 31% mFI2, 27% mFI3, and 19% mFI4; 64% men and 36% women). An increase in mFI-5 was associated with higher 30-day mortality (mFI1=0.62%; mFI12=1.45%; mFI13=1.35%; and mFI14=3.09%; P<.0001). After adjustment for age, mFI4 was associated with increased mortality compared with mFI1 (odds ratio, 3.80; 95% confidence interval, 1.69-8.54). Increased mFI-5 was associated with bleeding complications, wound infections, urinary tract infections, prolonged ventilation, sepsis, unplanned reoperations, and discharge to nonhome destination (all P<.01). Compared with mFI1 (13.5%), mFI4 was associated with increased 30-day readmission (24.8%, P<.0001). In patients undergoing LE bypass for CLI, higher mFI-5 was associated with increased postoperative complications, in-hospital and 30-day mortality, nonhome discharge, and 30-day readmission. The mFI-5 as an easily calculated tool can identify patients at high risk for inferior outcomes. It should be incorporated into discharge planning after LE bypass for CLI.

Preoperative Stress Test and Postoperative MI in Patients Requiring Lower Extremity Bypass for Critical Limb Ischemia

Patients with critical limb ischemia (CLI) often require lower extremity bypass surgery for limb salvage. A myocardial infarction (MI) is a major postoperative risk. Our objective is to assess the utility of preoperative stress test in determining patient outcomes. This is a retrospective study utilizing the national Vascular Quality Initiative database. We collected data from 2013-2018 on all patients undergoing lower extremity bypass for CLI and assessed whether or not they had a preoperative stress test. Rates of an MI were then compared between groups of patients who either did not receive a stress test, had a normal stress test or a positive stress test. An MI was distinguished as troponin only and electrocardiogram (EKG)/clinical. Our secondary end point was in-hospital mortality. Univariate and multivariate analysis with the stress test as a covariate was used to determine significance. During this time period, 29,937 bypasses were performed on 27,219 patients. The average age was 67.5 years (±11.09), 66.3% were men, and 17.3% were African American. Risk factors included hypertension (89.5%), diabetes (55.9%), congestive heart failure (20%), coronary artery disease (32.5%), coronary artery bypass graft (22.2%), and percutaneous coronary intervention (21%). 19,108 patients (64.1%) did not undergo the stress test before bypass, 6,830 (22.9%) had a normal stress test, and 2,898 (9.7%) had a positive stress test. Overall rate of an MI was 4%, with 2% being troponin only and 2% EKG/clinical. The positive stress test had a higher rate of troponin only (2.85%) as well as EKG/clinical (3.37%) MI. For every 10year increase in age, the odds of having a postoperative MI increased by 27% (P<0.0001). Overall in-hospital mortality was 1.4%. Patients with positive stress tests had a 2.6% mortality compared with normal/not performed at 1.3%. Of the patients who died, 21.5% had an EKG/clinical MI. Of those patients, 50% did not have a stress test, 12% had normal stress tests, and 23% had positive stress tests. When comparing rates of patients who died or had an MI, there was no difference between patients who had no or a normal stress test (7.29%) versus those who had a positive stress test (7.58%), (P=0.11). A positive stress test before lower extremity bypass is a significant predictor of a postoperative MI. However, mortality increase was minimal in patients with a positive stress test. Therefore, the stress test result should not delay care for patients needing urgent revascularization.

Unplanned readmissions after endovascular intervention or surgical bypass for critical limb ischemia

ObjectiveAfter surgery or other interventions, unplanned readmissions are associated with poor outcomes and drain health care resources. Patients with critical limb ischemia (CLI) are at particularly high risk of readmission, and readmissions result in increased health care costs. The primary aims of the study were to discover and compare the 30-day readmission rates of patients who underwent lower extremity surgical bypass (LEB) and endovascular infrainguinal endovascular intervention (IEI) for CLI and to evaluate the relationship between unplanned readmissions likely related to the primary procedure for IEI compared with LEB. MethodsThe Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify all infrainguinal LEB or IEI for CLI from 2015 to 2018. Those who were not eligible for the primary outcome of interest were excluded. The primary 30-day outcome was unplanned readmission. Univariate analyses for primary and secondary outcomes were performed using Fisher's exact and Wilcoxon rank-sum testing. Multivariate analysis was performed using inverse probability weighting and independent risk factors for readmission were identified with logistic regression. ResultsThere were 12,873 patients who met inclusion criteria. In the LEB cohort, there were 7270 (56.5%) patients, and in the IEI cohort, there were 5603 (43.5%) patients. Thirty percent (n = 1696) of the IEI cohort underwent a tibial intervention, and 49% (n = 3547) underwent a distal bypass. The IEI cohort was more likely to be high physiologic risk (P < .001) and to present with tissue loss (P < .001), whereas the LEB cohort was more likely to have high anatomic risk features (P < .001) and be performed under emergent conditions (P < .001). After multivariable analysis, LEB was found to be independently predictive for both unplanned readmissions due to any cause (adjusted odds ratio, 1.35; 95% confidence interval, 1.22-1.51; P < .001) and procedure-related unplanned interventions (adjusted odds ratio, 1.85; 95% confidence interval, 1.63-2.11; P < .001). Independent predictors of readmission were LEB, preoperative sepsis, severe chronic kidney disease, dependent functional status, insulin-dependent diabetes mellitus, high-risk physiologic features, African American race, preoperative steroid use, history of severe chronic obstructive pulmonary disease, and preoperative tissue loss. ConclusionsLEB is independently associated with unplanned readmission from all causes and from procedure-related causes after adjusting for the measured confounders. More research is required to determine the economic burden of these readmissions.

Long-Term Results and Risk Analysis of Redo Distal Bypass for Critical Limb Ischemia

Distal bypass is the optimal treatment for patients with critical limb ischemia (CLI). However, effectiveness of redo distal bypass (rDB) after failed initial distal bypass (iDB) remains uncertain. This study aimed to analyze long-term results of rDB for CLI. Patients undergoing rDB for CLI from 2009 to 2018 at a single institute were retrospectively reviewed. Operative details, primary and secondary patency, survival rate, major amputation-free rate, and risk factors affecting patency were analyzed. The distal runoff was evaluated using the infrapopliteal Global Limb Anatomic Staging System (GLASS) grade (0 to 4: 0 represents good runoff and 4 represents the poorest runoff). Of 310 iDB (251 patients), 46 rDB were performed in 44 patients: 27 men, mean age 75±10years, diabetes mellitus 77%, chronic renal failure with hemodialysis 45%. Only the autologous veins were used in distal bypasses: a great saphenous vein (GSV) in 28 (57%), a small saphenous vein in 13 (27%), an arm vein in 6 (12%), and a superficial femoral vein in 2 (4%). The GSV was used less frequently for rDB than for iDB (57% vs. 90%, P<0.0001). The infrapopliteal GLASS grade 4 was recognized more in rDB than iDB (76% vs. 60%, P=0.04). Primary and secondary patency of rDB was 25% and 44% at 1year and 14% and 29% at 3years, respectively, which were significantly lower than those of iDB (P<0.0001). The survival rate after rDB was 68% at 1year and 53% at 3years. Freedom from major amputation rate in rDB was 83% at 1year and 66% at 3years. Multivariate analysis showed the risk factor influencing on secondary patency was patent duration of the iDB graft (P=0.012). Secondary patency of rDB was higher in the group of late graft occlusion ≥6months after iDB (late group) than in the group of early graft occlusion<6months after iDB (early group) (94% vs. 9% at 1year and 75% vs. 5% at 3years, P<0.0001). However, freedom from major amputation rate at 3years was comparable between both groups (71% in the late group vs. 61% in the early group). Patency of rDB was significantly lower than that of iDB partly because of less use of the GSV and poorer runoff. Because survival and graft patency after rDB was low, rDB should be a suboptimal treatment especially in patients with early graft occlusion within 6months after iDB.

The Impact of Anaemia on The Clinical Outcomes of Infra-Inguinal Bypass for Critical Limb Ischaemia

Introduction: Anaemia in elective cardio-vascular surgery has been shown to have a detrimental impact on clinical outcomes and survival. Non-elective caseload is high in vascular surgery and the timely revascularisation in critical limb-ischaemia (CLI) significantly contributes towards this workload. The outcomes are hugely significant to the patient. Equally a 2017 Delphi consensus identified that improving outcomes in CLI are a top ten research priority. As such, this tertiary centre cohort study evaluates the impact of anaemia on CLI revascularisation outcomes. Methods: All infra-inguinal bypass operations for CLI between 2016 and 2018 were identified from a prospectively maintained database. Anaemia was defined as a pre-operative haemoglobin (Hb) of less than 120g/dL. ROC analysis was performs to support this ´cut-off´ Hb. Pre-, intra- and post-operative metrics were analysed to understand if anaemia impacted on clinical outcome. Comparative statistics and regression analyses were performed. Results: 124 bypasses for CLI were included. 45 were anaemic with an average Hb of 105 (9.5) vs. the non-anaemic 141.7 (14.7) group. Baseline comparisons were equivalent for age, gender, co-morbidity and medications, as were the duration of surgery and intra-operative blood loss. Post-operatively there was a greater rate of wound infection (p=0.036) and myocardial infarction (p=0.02) in the anaemic group. Regression analysis demonstrated that anaemic patients were 9(OR) times more likely to have an MI. The mean length of stay was longer in the anaemic group (26.8 (22.6) vs. 14(15.9) days (P=0.001). 1-year mortality was also higher in the anaemic group(P=0.037) and OR of 3.6(1.02 - 12.8)(P=0.046). Anaemia and length of stay significantly correlated with 1-year mortality. There was no difference in 30-day mortality or limb loss. A Hb of 111was the most sensitive and specific critical Hb for both MI and 1-year mortality. Conclusion: Pre-operative anaemia significantly increases the rate of complications and length of hospital stay following surgical revascularisation for CLI. It is also associated with higher 1-year mortality. Consequently, optimisation of baseline Hb may improve these outcomes in this high risk non-elective group of patients. Disclosure: Nothing to disclose

Preoperative Nutritional Status is an Independent Predictor of the Long-Term Outcome in Patients Undergoing Open Bypass for Critical Limb Ischemia

The nutritional status before treatment has been reported to be significantly associated with the prognosis of patients with various diseases. The aim of this study was to examine whether or not this applies to patients undergoing open bypass for critical limb ischemia (CLI). The preoperative nutritional status of patients who underwent de novo infrainguinal bypass for CLI from January 2000 to December 2017 was retrospectively evaluated using the geriatric nutritional risk index (GNRI) and controlling nutritional status (CONUT) score. Patients were divided into 4 groups based on the GNRI or CONUT score; group I, normal nutrition; group II, mild malnutrition; group III, moderate malnutrition, and group IV, severe malnutrition. The amputation-free survival (AFS), overall survival (OS), and limb salvage (LS) rates up to 5 years were calculated by Kaplan-Meier method and a Cox proportional hazard regression analysis was performed to elucidate whether or not the nutritional indices were independently associated with these outcomes. A total of 373 patients were included. The median observation term was 969days. There were significant differences in the AFS and OS of the 4 groups divided based on the GNRI and CONUT score. The 2- and 5-year AFS rates of groups I, II, III, and IV, divided based on the GNRI, were 81% and 56%, 72% and 48%, 56% and 27%, and 56% and 12%, respectively (P<0.001), while those based on the CONUT score were 75% and 55%, 72% and 41%, 50% and 6%, and 30% and 30%, respectively (P<0.001). The GNRI (groups III+IV) was an independent predictor of AFS (Hazard ratio [HR], 1.85; 95% confidence interval [CI], 1.27-2.69; P<0.001) and OS (HR, 2.26; 95% CI, 1.50-3.41; P<0.001), while the CONUT score (groups III+IV) was also an independent predictor of AFS (HR, 1.68; 95% CI, 1.13-2.49; P=0.011) and OS (HR, 1.64; 95% CI, 1.07-2.49; P=0.024). However, neither nutritional index was an independent predictor of LS. The preoperative nutritional status, as measured by the GNRI or CONUT score, was significantly associated with AFS and OS in patients undergoing infrainguinal bypass for CLI.

Propensity Score–Adjusted Comparison of Long-Term Outcomes Among Revascularization Strategies for Critical Limb Ischemia

Few studies have compared long-term outcomes among specific treatment modalities for critical limb ischemia. The aim of this study was to compare long-term outcomes with percutaneous transluminal angioplasty (PTA), stent placement, atherectomy, or surgical bypass in patients diagnosed with critical limb ischemia. In this observational study using Medicare claims data, we identified incident cases with a primary critical limb ischemia diagnosis who received PTA, stent placement, atherectomy, or surgical bypass. We used propensity score weighting to determine the association of treatment type with all-cause mortality and major (above ankle) amputation over 4 years follow-up. Among 36 860 patients (10 904 PTA; 11 295 stent placement; 4422 atherectomy; 10 239 surgical bypass), all-cause mortality over 4 years was 49.3% with atherectomy, 51.4% with surgical bypass, 53.7% with stent placement, and 54.7% with PTA (P<0.05 for all pairwise comparisons). Major amputation rates over 4 years were 6.8% with atherectomy, 7.8% with stent placement, 8.1% with PTA, and 10.8% with surgical bypass (P<0.05 for all pairwise comparison except PTA versus stent). Among Medicare beneficiaries who received PTA, stent placement, atherectomy, or surgical bypass for critical limb ischemia, high mortality and major amputation rates were observed with minor differences among treatment groups. Statistically significant group differences of uncertain clinical importance were observed for several comparisons. Results from observational research may be susceptible to bias because of unmeasured confounders and, therefore, these comparative results should be interpreted with caution.

Graft flow predictive equation in distal bypass grafting for critical limb ischemia

ObjectiveGraft flow (GF) seems to be an important prognostic predictor in distal bypass for critical limb ischemia, but previous studies have failed to clarify the association between GF and the graft prognosis. GF differs significantly among grafts, and each graft seems to have an optimal GF depending on various factors. We hypothesized that comparison between the measured GF (mGF) and optimal estimated GF (eGF) would be important in predicting graft prognosis. Herein, we aimed to develop a GF predictive equation by assessing GF determinants and to validate the equation against a clinical dataset. MethodsA total of 198 distal bypasses with vein grafts for critical limb ischemia from 2011 to 2016 were enrolled. Of these grafts, 135 normal grafts without any abnormalities on early postoperative ultrasound examination were used to develop and validate the equation. Various anatomic and patient-related factors were analyzed to detect GF determinants with stepwise selection, and the GF predictive equation was developed with multiple linear regression analysis. After developing the equation, all 198 grafts were categorized into two groups according to the equation developed based on data from the 135 normal grafts as follows: optimal flow grafts (OFGs), in which mGF > eGF – 14.6, and suboptimal flow grafts (SFGs), in which mGF < eGF – 14.6. The cutoff value of 14.6 was determined using receiver operating characteristic curves to detect graft abnormalities. By comparing OFGs and SFGs, the efficacy of the equation in predicting bypass abnormalities and graft prognosis was assessed. ResultsThe GF determinants were runoff, hemodialysis (HD), diabetes mellitus (DM), and graft quality (GQ). The predictive equation was estimated as follows: GF(ml/min)=(32.9×run-off)+(9.9×GQ)−(13.0×DM)−(35.1×HD)+12.1 (R2 = 0.71, coefficient: runoff and GQ, 3 [good], 2 [fair], 1 [poor]; DM and HD, 1 [yes], 0 [no]). In the efficacy assessment of the equation, SFGs showed a significantly higher rate of bypass abnormalities (64.0% vs 12.2%; P < .0001), graft intermediate stenosis (10.7% vs 1.6%; P = .0071), graft critical stenosis (28.0% vs 3.2%; P < .0001), and early graft occlusion (17.3% vs 4.3%; P = .0037) than OFGs and were associated with a higher rate of revision surgery within 2 years after surgery (50.7% vs 34.2%; P = .026). SFGs also showed significantly lower primary patency rates (P < .0001) and secondary patency rates (P = .0005). ConclusionsGF was well-estimated with runoff, GQ, and the presence of DM and HD. A comparison between mGF and eGF, calculated with the equation, will help to detect bypass abnormalities and determine the necessity of additional intraoperative procedures and, thus, achieve optimal outcomes.

The impact of chronic kidney disease on lower extremity bypass outcomes in patients with critical limb ischemia

ObjectivePatient selection for open lower extremity revascularization in patients with chronic kidney disease (CKD) remains a clinical challenge. This study investigates the impact of CKD on early graft failure, postoperative complications, and mortality in patients undergoing lower extremity bypass for critical limb ischemia. MethodsThe National Surgical Quality Improvement Program database was queried for all patients with critical limb ischemia from 2012 to 2015 who underwent lower extremity bypass using the targeted vascular set. The glomerular filtration rate was calculated using the Chronic Kidney Disease Epidemiology Collaboration Study equation. CKD categories were determined from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative staging criteria. Patients were classified into three groups: CKD stages 3 or lower (mild to moderate CKD), CKD stages 4 or 5 (severe CKD), and on hemodialysis (HD). Multiple variable analysis was used to examine graft failure, mortality, and postoperative complications. ResultsThe Surgical Quality Improvement Program database identified 6978 patients who underwent infrainguinal lower extremity arterial bypass during the study period. There were 6101 patients (87.4%) with mild to moderate CKD, 327 (4.7%) with severe CKD, and 550 (7.9%) on HD. Patients with severe CKD and on HD were more likely to have revascularization for tissue loss (54.9% vs 68.8% and 74.7%; P < .01). Patients with severe CKD and those on HD had higher rates of early graft failure, postoperative myocardial infarction, and rates of reoperation. Multiple variable analysis confirmed these results showing that HD was associated with postoperative myocardial infarction, readmission, and increased mortality. It also demonstrated that severe CKD was associated with graft failure (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.12-2.50; P = .01), postoperative myocardial infarction (OR, 2.16; 95% CI, 1.35-3.45; P < .01), and readmission (OR, 1.38; 95% CI, 1.06-1.80; P = .02). Other factors associated with graft failure include functional status (OR, 1.39; 95% CI, 1.08-1.80; P = .01), African American race (OR, 1.72; 95% CI, 1.39-2.13; P < .01), and distal bypass (OR, 1.33; 95% CI, 1.09-1.61; P < .01). ConclusionsCKD is a significant predictor of perioperative morbidity after lower extremity bypass. Patients with severe CKD have worse postoperative outcomes without increased mortality. Those on HD have worse survival and postoperative outcomes.

Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia

Patients with critical limb ischemia (CLI) utilize hospital resources at high rates. One major driver for resource utilization is emergency department (ED) visits. Our goal was to assess perioperative ED visits after lower extremity bypass (LEB) for CLI. All patients undergoing LEB for CLI from 2008 to 2017 at our institution were analyzed. ED visits and details of the visit within 30 and 90days of discharge from index admission were recorded. Multivariable analysis was performed to identify risk factors for any ED presentation and ED presentation without hospital admission. There were 317 patients identified who underwent infrainguinal LEB for CLI. Average age was 66 years, and 60.6% of patients were male. Within 30 and 90days, 24.3% and 36.3% presented to the ED overall, and 16.7% and 26.5% of all postoperative patients had an ED presentation without hospital admission, respectively. Most common reasons for any ED visits and for ED visits without admission within 30days were wound complications (22.1% and 20.8%), cardiac complications (16.9% and 17%), and ipsilateral leg pain (10.4% and 11.3%), respectively. Cryopreserved vein bypass (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.02-8.84, P=0.046) and index length of stay (LOS) (OR 1.09, 95% CI 1.04-1.15, P<0.001) predicted any 30-day ED visit. Active leg infection at the time of bypass (OR 2.35, 95% CI 1.21-4.58, P=0.012) and index LOS (OR 1.05, 95% CI 1.004-1.09, P=0.033) predicted 30-day ED presentation without hospital admission. Most common reasons for any ED visit and for ED visits without admission within 90days were surgical wound complications (15.8% and 14.3%), cardiac complications (14.9% and 14.3%), and nonsurgical wounds (9.6% and 9.5%), respectively. Chronic renal insufficiency (CRI) (OR 2.73, 95% CI 1.52-4.93, P=0.001) and index LOS(OR 1.07, 95% CI 1.01-1.12, P=0.017) predicted any 90-day ED visit. CRI (OR3.34, 95% CI 1.81-6.17, P=0.001) predicted 90-day ED presentation without hospital admission. For multiple ED visits within 90days, there were 5 patients each with 5 ED visits, 12 each with 4 ED visits, 26 each with 3 ED visits, and 47 each with 2 ED visits. There is a high rate of ED utilization in CLI patients after LEB. Targeting these patients with closer follow-up and improved outpatient ambulatory access could assist in decreasing the frequency of postoperative ED visits. Particular areas of targeted improvement are those patients who presented to the ED and were not admitted.

Emergency Department Utilization is High after Lower Extremity Bypass for Critical Limb Ischemia

Emergency Department Utilization is High after Lower Extremity Bypass for Critical Limb Ischemia

Knacks and Pitfalls of Surgical Bypass for Critical Limb Ischemia

Knacks and Pitfalls of Surgical Bypass for Critical Limb Ischemia

Barthel Index and Outcome of Open Bypass for Critical Limb Ischemia.

Daily activity should be an important factor to consider when deciding on a treatment strategy for critical limb ischemia (CLI), and we hypothesized that there was a close relationship between activities of daily living (ADL) and prognosis. The aim of this study was to investigate the association between ADL and outcomes of open bypass for CLI.Methods and Results:A total of 226 patients undergoing infrainguinal bypass for CLI between January 2005 and December 2015 were reviewed. They were divided into 2 groups based on Barthel index (BI) at admission (pre-BI; ≥60 and <60) and compared with respect to the incidence of early adverse events and 3-year overall survival and amputation-free survival. Adverse events were more frequently observed in patients with pre-BI <60. Patients with pre-BI <60 had worse long-term outcomes. On multivariable analysis, hypoalbuminemia, end-stage renal disease, and BI at discharge <60 were significant predictors of 3-year outcomes, whereas pre-BI <60 was not a significant predictor of either outcome. It is not BI at admission, but BI at discharge that determines long-term outcome.

TCT-165 ESRD patients undergoing angioplasty and bypass for CLI have worse outcomes compared to non-ESRD patients: A meta-analysis

Critical limb ischemia (CLI) is a severe form of PAD. ESRD is associated with increased morbidity and mortality following lower extremity amputation. Therefore, both angioplasty and bypass are used in ESRD patients with CLI; however, the treatment of choice remains controversial. We aimed to

Comparison of Long-term Outcomes of Heparin Bonded Polytetrafluoroethylene and Autologous Vein Below Knee Femoropopliteal Bypasses in Patients with Critical Limb Ischaemia

Endovascular first is the preferred therapy approach to critical limb ischaemia (CLI). However, in spite of new endovascular techniques, bypass surgery still plays an important role, especially in patients with complex anatomy in whom endovascular therapy is not considered feasible, or has failed. The goal of this study was to analyse the outcomes of prosthetic or autologous vein for femoropopliteal (P3) bypasses performed under the abovementioned conditions. A retrospective analysis of patients who underwent a femoropopliteal (P3) bypass for CLI (March 2007–December 2015) was conducted. Endovascular therapy was not possible. Patency rates, limb salvage, major adverse limb event (MALE) free survival, and survival after 5 years were analysed. In total, 151 cases were included in the analysis (rest pain 35.8%, ulcer/gangrene 64.3%). The graft material was autologous vein in 76 cases (vein group) and heparin bonded expanded polytetrafluoroethylene (HePTFE) in 75 cases (HePTFE group). Indications, risk factors, previous revascularisation procedures, and runoff vessels were similar in both groups. Thirty day mortality was 6.6% in the vein group and 5.3% in the HePTFE group (P = .508), early graft occlusion (6.6% vs 5.3%; P = .508) and 30 day major amputation rate (0% vs 2.7%; P = .245) were similar between the two groups. Overall primary patency was 51.7% (55.5% [vein group] vs 51.7% [HePTFE group]; P = .897) and overall secondary patency was 64.2% (74.6% [vein group] vs 55.6% [HePTFE group]; P = .119), all without significance after 5 years. However, limb salvage (79.1%) was significantly different (90.0% [vein group] vs 62.9% [HePTFE group]; P = .021). Survival was similar between the groups (47.3% vs 42.9%; P = .582) as well as MALE free survival (69.4% vs 55.0%; P = .348). Bypasses to the below knee popliteal artery show good results in patients with CLI unsuitable for endovascular therapy. Vein is still the first line graft material.