Infrapopliteal Bypass Research Articles

Peripheral arterial occlusive disease operative case volume in the final years of 5+2 and 0+5 vascular training paradigms

BackgroundPeripheral arterial occlusive disease constitutes a substantial portion of clinical practice in vascular surgery and, as such, trainees must graduate with proficiency in endovascular and open procedures to become capable vascular surgeons. Case volume for 0+5 integrated vascular surgery residents in the chief and junior years was compared with their 5+2 fellowship counterparts for the treatment of peripheral arterial occlusive disease. MethodsIn this retrospective review, operative volume for peripheral arterial occlusive disease cases in both vascular training paradigms was evaluated. “Surgeon chief” cases in the final year of residency training, and “surgeon junior” cases for postgraduate year 4 and below were gathered for the integrated vascular surgery residents group. Annual fellow’s case volume was collected using cases logged as “surgeon fellow.” Procedures were divided by the following anatomic region and compared: aortoiliac, femoropopliteal, and infrapopliteal. Student’s t tests were used to assess these differences. ResultsAn aggregate of 887 residents and fellows from 137 programs were identified. Vascular surgery fellows consistently performed 1.7-fold (P < .001) and 1.6-fold (P < .001) more total peripheral cases than their integrated vascular surgery residents chief and junior counterparts, respectively. They also performed 1.8-fold (P = .002) and 1.5-fold (P = .004) more peripheral endovascular cases than their 0+5 chief and junior counterparts respectively. With respect to endovascular treatment of peripheral arterial occlusive disease by subgroup, we found the overall volume of aortoiliac and femoropopliteal increased, whereas infrapopliteal case volume decreased. Vascular surgery fellows were performing many more of these cases per year than the integrated vascular surgery residents chiefs and junior residents. When looking at 3 index open procedures, aortobifemoral bypass, femoropopliteal bypass with vein, and infrapopliteal bypass with vein in the academic year 2017–2018, the vascular surgery fellow trainees performed more cases than the integrated vascular surgery residents chief and junior residents. ConclusionEarlier studies have compared the operative volume of vascular surgery fellows and integrated vascular surgery residents in their entire tenure of training. Our study specifically evaluated the years of training that confer the greatest level of autonomy. Vascular surgery fellows are performing more endovascular and open cases than their 0+5 counterparts for peripheral arterial occlusive disease during the final phase of training. These findings suggest that current suspected equipoise of vascular surgery training paradigms may not reflect what is occurring in practice and therefore warrants further investigation.

Efficacy of Two-Dimensional Perfusion Angiography for Evaluations after Infrapopliteal Bypass Surgery for Critical Limb Ischemia.

Two-dimensional perfusion angiography (2DPA) is utilized in hybrid operating rooms. 2DPA produces color map images and functional parameters to provide more robust visual and quantitative evaluations than conventional angiography. Its efficacy was suggested in five patients following bypass surgery; unexpected results were obtained in one patient, leading to a decision to perform surgical re-anastomosis. Furthermore, we found that the general anesthesia eliminates body movements that tend to disrupt 2DPA results. 2DPA was more useful during surgical revascularization than conventional angiography and provided more detailed information.

Bypass Surgery after Endovascular Therapy for Infrapopliteal Lesion Is Not a Poor Outcome Compared with Initial Bypass Surgery by Vascular Surgeons

It is unclear whether prior endovascular therapy (EVT) adversely affects bypass surgery. The aim of this study is to investigate treatment outcomes between initial bypass (bypass-first) and bypass surgery after EVT (EVT-first). We conducted a retrospective analysis of critical limb ischemia patients undergoing infrapopliteal bypass between November 2006 and December 2015. Graft patency, limb salvage (LS), amputation-free survival (AFS), and overall survival (OS) were examined between bypass-first and EVT-first groups. The subjects in this study were 75 patients and 82 limbs in the bypass-first group and 24 patients and 24 limbs in the EVT-first group. The average age was higher in EVT-first group (P=0.03). The percentage of inframalleolar bypass was higher in the EVT-first group(P=0.002). Primary patency at 1 and 2years was 72.0% and 67.5% for the bypass-first group and 53.1% and 47.2% for the EVT-first group, respectively (P=0.04). Inframalleolar bypass was a risk factor for lower primary patency (hazard ratio 3.07, 95% confidence interval 1.18-8.51, P=0.02) in multivariate analysis, while there were no differences in secondary patency, LS, AFS, and OS. Bypass surgery after EVT has lower primary patency rates in comparison with primary bypass in patients submitted to infrapopliteal revascularization. Although very heterogeneous study population with a lot of bias in the indication of the revascularization, LS, OS and AFS are not affected by previous EVT.

Regional variation in patient selection and treatment for lower extremity vascular disease in the Vascular Quality Initiative

ObjectivePrior studies on the cause and effect of surgical variation have been limited by utilization of administrative data. The Vascular Quality Initiative (VQI), a robust national clinical registry, provides anatomic and perioperative details allowing a more robust analysis of variation in surgical practice. MethodsThe VQI was used to identify all patients undergoing infrainguinal open bypass or endovascular intervention from 2009 to 2014. Asymptomatic patients were excluded. The 16 regional groups of the VQI were used to compare variation in patient selection, operative indication, technical approach, and process measures. χ2 analysis was used to assess for differences across regions where appropriate. ResultsA total of 52,373 interventions were included (31%). Of the 16,145 bypasses, 5% were performed for asymptomatic disease, 26% for claudication, 56% for chronic limb-threatening ischemia (CLI) (61% of these for tissue loss), and 13% for acute limb-threatening ischemia. Of the 35,338 endovascular procedures, 4% were for asymptomatic disease, 40% for claudication, 46% for CLI (73% tissue loss), and 12% for acute limb-threatening ischemia. Potentially unwarranted variation included proportion of prosthetic conduit for infrapopliteal bypass in claudication (13%-41%, median, 29%; P < .001), isolated tibial endovascular intervention for claudication (0.0%-5.0%, median, 3.0%; P < .001), discharge on antiplatelet and statin (bypass: 62%-84%; P < .001; endovascular: 63%-89%; P < .001), and ultrasound guidance for percutaneous access (claudication: range, 7%-60%; P < .001; CLI: 5%-65%; P < .001). Notable areas needing further research with significant variation include proportion of CLI vs claudication treated by bypass (38%-71%; P < .001) and endovascular intervention (28%-63%; P < .001), and use of closure devices in percutaneous access (claudication; 26%-76%; P < .001; CLI: 30%-78%; P < .001). ConclusionsSignificant variation exists both in areas where evidence exists for best practice and, therefore, potentially unwarranted variation, and in areas of clinical ambiguity. Quality improvement efforts should be focused on reducing unwarranted variation. Further research should be directed at identifying best practice where no established guidelines and high variation exists.

Complex infrapopliteal revascularization in elderly patients with critical limb ischemia: impact of multidisciplinary integrated care on mid-term outcome.

The incidence of critical limb ischemia (CLI) is exponentially rising among our aging population. There is a paucity of scientific evidence on best management and clinical outcome of infra-popliteal (IP) revascularizations in elderly CLI patients. A prospectively collected database was analyzed to identify consecutive octogenarian and nonagenarian patients who underwent IP revascularizations (bypass or angioplasty) for CLI (Rutherford 4-6) in a single center between 2010-2014. The primary end points were overall amputation-free-survival (AFS) and overall survival (OS) at 1 and 2 years. Secondary endpoints were primary, assisted-primary, secondary patency and limb-salvage (LS) rates by Kaplan-Meier analysis. Univariate and multivariate analysis was performed to find factors predicting outcome. A total of 129 limbs in 120 patients were treated with IP bypass (N.=42) and endovascular (N.=87) revascularizations with a mean age of 85(±5) years. The overall primary patency, assisted-primary patency and secondary patency were 58%, 65% and 70%, respectively at 12 months and 34%, 48% and 59% at 24 months. Primary, assisted-primary and secondary patency analyzed by treatment method (endovascular vs. bypass) was 54% vs. 52%, 61% vs. 70%, 69% vs. 75% at 1 year and 21% vs. 36%, 24% vs. 62%, 31% vs. 72% at 2 years. The overall AFS at 12 and 24 months was 62% and 46% respectively; AFS was 71%-68% in the bypass group and 53-21% in the Endovascular group (P<0.001). LS was 89% at 12 months and 84% at 24 months, with no significant difference between the bypass and endovascular groups (P=0.24). The overall perioperative mortality rate was 2%. OS by Kaplan-Meier was 68% and 54% at 1 and 2 years respectively. Diabetes (P=0.046) and low eGFR (P=0.041) were predictors of worse AFS and OS, respectively. IP revascularizations (either endovascular or surgical) is feasible and effective in octogenarians and nonagenarians with CLI. By adopting a patient-tailored approach, both revascularizations strategies have satisfactory technical and clinical outcomes in this high-risk group. Subgroup analysis suggests that bypass surgery may have better mid-term secondary patency and AFS rates.

The efficacy of salvage interventions on threatened distal bypass grafts

Infrapopliteal bypass is an established and effective method for limb salvage in patients with critical limb ischemia. Secondary interventions maybe required to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions. Consecutive patients undergoing bypasses onto the infrapopliteal vessels for critical limb ischemia (Rutherford 4-6) at a single institution were analyzed between 2009 and 2013. The primary end points were graft patency, amputation-free survival (AFS), and freedom from reintervention at 12 months by Kaplan-Meier analysis. A total of 114 infrapopliteal bypasses were performed in 102 patients. Distal anastomosis was on to the anterior tibial (n = 31), posterior tibial (n = 27), peroneal (n = 24), tibioperoneal trunk (n = 23), or dorsalis pedis artery (n = 9). Primary patency, assisted primary patency, and secondary patency was 57%, 76%, and 82%, respectively, at 12 months and 44%, 70%, and 80%, respectively, at 36 months. AFS was 80% at 12 months and 65% at 36 months. Endovascular salvage interventions were performed on 58 grafts (51%) including angioplasty of inflow/proximal anastomosis (33%), outflow/distal anastomosis (46%), and graft stenosis (20%), with a further 12 grafts (11%) undergoing thrombolysis for occlusion. Surgical salvage interventions included jump grafts (n = 7), revision of anastomotic stenosis (n = 3), and thrombectomy (n = 2). AFS was similar in salvaged threatened and acutely occluded grafts compared with nonthreatened grafts (P = .064) and better in grafts requiring reintervention later (>6 months from bypass) compared with those requiring early reintervention (<6 months; P = .047). Secondary interventions in threatened distal bypass grafts are successful at maintaining graft patency and AFS when compared with nonthreatened grafts, and are associated with a low morbidity rate.

Outcome of Infra-popliteal Bypass Grafts Using the Distal Superficial Femoral or Popliteal Arteries for Inflow in Critical Leg Ischemia

(median age; 72 years; range; 45-91 years). The primary, assisted primary, and secondary patency rates at 1 year were 57%, 80%, and 89%, respectively. The amputationfree survival at 1 year was 92%. At 1 year, 82 % of the patients were free of endovascular reintervention. There were no early 30-day mortalities; however, six patients died within 1 year (4.8%). Eight patients underwent RFE in combination with a distal bypass, and all but one required multiple endovascular reinterventions within 1 year. All combined RFE/distal bypasses were patent at 1 year. Conclusions: Hyb revascularization allows for treatment of multilevel disease in CLI patients. Amputationfree survival at 1 year was 92%, and primary, assisted primary, and secondary patency rates were 57%, 80%, and 89%. Similarly, favorable results were seen with distal bypass surgery combined with RFE, with 100% patency rates at 1 year. Duplex surveillance and salvage angioplasty are essential in maintaining graft patency.

Blauzdos arterijų endovaskulinių procedūrų ir šuntų į pėdos arteriją rezultatų analizė

Įvadas/tikslas Blauzdos arterijų angioplastika yra vertinga galūnės išsaugojimo procedūra ligoniams, sergantiems kritine kojų išemija. Esant blauzdos arterijų užakimui, dažniausiai atliekama arterijų šuntavimo operacija. Šio tyrimo tikslas buvo parodyti mūsų gydymo rezultatus bei palyginti arterijų šuntavimo operacijų į pėdos arteriją ir blauzdos arterijų perkutaninės transliuminalinės an­gioplastikos vėlyvuosius rezultatus esant kritinei kojos išemijai. Taip pat įvertinti cukrinio diabeto įtaką operacijų rezultatams. Metodai Retrospektyviuoju būdu išanalizuotos visos gydomosios blauzdos arterijų procedūros, atliktos nuo 1999 m. sausio iki 2013 m. gruodžio mėnesio. Buvo palyginti blauzdos arterijų perkutaninės transliuminalinės angioplastikos ir atviros chirurgijos – šun­tų į pėdos arteriją gydymo rezultatai. Išanalizuota cukrinio diabeto įtaka gydymo rezultatams. Rezultatai Sudarytos trys pacientų grupės: I grupė – 193 ligoniai, kuriems atliktos šuntavimo į pėdos arteriją operacijos; II grupė – 103 atvejai 98 pacientams, kuriems atlikta blauzdos arterijų perkutaninė transliuminalinė angioplastika; III grupė – 84 pacientai, kuriems taikytas sudėtinis gydymas – perkutaninė transliuminalinė angioplastika ir šuntavimas į pėdos arteriją. Kumuliacinis kraujotakos atkūrimas po 1 metų atlikus atvirą operaciją – 47,5 %, atlikus blauzdos arterijų angioplastiką – 6,9 %, atlikus sudėti­nį gydymą – 79,6 %. Geriausi rezultatai gauti sudėtinio gydymo grupėje (p&lt;0,007). Galūnės išsaugojimas po vienų metų atlikus operaciją – 84,1 %, po endovaskulinės chirurgijos – 35,4 %, po sudėtinio gydymo – 83,1 %. Ilgesnį laikotarpį galūnės išsaugotos po sudėtinio chirurginio gydymo (p&lt;0,001). Cukriniu diabetu segantiems ligoniams kumuliacinis kraujotakos atkūrimas praė­jus vieniems metams po šuntavimo į pėdos arteriją operacijų – 60,4 %, nesergantiems cukriniu diabetu – 21,8 % (p=0,013), po atliktos blauzdos arterijų angioplastikos cukriniu diabetu sergantiems ligoniams – 3,6 %, nesergantiems – 10,1 %. Kumuliacinis kraujotakos atkūrimas, praėjus dvejiems metams po rekonstrukcinių procedūrų, jei cukrinis diabetas kompensuotas, sudarė 55,2 %, o jei nekompensuotas – 43,6 %. Galūnės išsaugojimas esant kompensuotam cukriniam diabetui sudarė 79,31 %, o nekompensuotam – 61,82 %. Rezultatas nėra statistiškai patikimas (p&gt;0,05). Išvados Blauzdos arterijų angioplastika ir šuntavimo operacija yra tinkamos procedūros išsaugoti galūnę ligoniams, sergantiems kri­tine galūnės išemija. Vėlyvieji kraujotakos atkūrimo rezultatai buvo geresni po šuntavimo į pėdos arteriją atliktų operacijų. Geriausi kraujotakos atkūrimo rezultatai ligoniams, sergantiems cukriniu diabetu, pasiekti taikant sudėtinį gydymo metodą – angioplastiką ir atvirą operaciją. Šuntavimas į pėdos arteriją yra saugi ir efektyvi procedūra cukriniu diabetu sergantiems pacientams, turintiems kritinę kojos išemiją. Glikozilinto hemoglobino kiekis neturi įtakos kraujotakos atkūrimo rezultatams.

Clinical outcome after infrapopliteal bypass surgery in chronic hemodialysis patients with critical limb ischemia

Lower extremity bypass surgery has been widely performed to treat critical limb ischemia (CLI) in patients on hemodialysis (HD). However, the clinical outcome still remains unclear. We investigated the limb salvage rate after infrapopliteal bypass surgery in HD patients with CLI. From April 2006 to January 2013, 226 patients with 236 limbs who electively underwent bypass surgery for treatment of CLI due to infrapopliteal disease were enrolled. Patients were grouped by those who were on HD (n = 177) and those who were not (n = 49). They were monitored for 5 years or until December 2013 if the follow-up period was <5 years. Amputation-free survival, defined as freedom from major amputation or all-cause death, was primarily evaluated. Incidence of reintervention was also analyzed. Ulcer/gangrene was present in 206 patients (91.2%), and 233 limbs (98.7%) were treated using autogenous vein. Age was younger (67 ± 9 vs 72 ± 9 years; P = .0011) and ulcer/gangrene was more prevalent (93.8% vs 81.6%, P = .0080) in HD patients than in non-HD patients. During the follow-up period (median, 28 months), 33 (14.6%) major amputations and 28 reinterventions (12.4%) occurred, and 65 patients (28.8%) died. The 5-year amputation-free survival rate was significantly lower in HD patients than in non-HD patients (43.6% vs 78.8%, P = .0033), and the adjusted hazard ratio (HR) for amputation or death for HD patients was 2.36 (95% confidence interval [CI], 1.13-4.92; P = .022). Compared with non-HD patients, the status of HD was similarly an independent risk of major amputation (72.4% vs 92.5%; adjusted HR, 4.36; 95% CI, 1.04-18.3; P = .045) and mortality (56.9% vs 83.2%; adjusted HR, 2.81; 95% CI, 1.30-6.09; P = .0085). However, freedom from reintervention was comparable between the two groups (84.3% vs 86.8%; P = .89). In HD patients, body mass index (HR, 0.86; 95% CI, 0.76-0.96; per 1 kg/m(2) increase; P = .014) and C-reactive protein (HR, 1.06; 95% CI, 1.01-1.11; P = .014) independently predicted major amputation. Elevated C-reactive protein levels were also associated with death (HR, 1.04; 95% CI, 1.01-1.09; P = .047). The clinical outcome after infrapopliteal bypass surgery was poorer in HD patients with CLI compared with non-HD patients. Malnutrition or chronic inflammation was associated with poor outcome in HD patients with CLI due to infrapopliteal occlusive disease.

Endovascular Therapy is Effective Treatment for Focal Stenoses in Failing Infrapopliteal Vein Grafts

To evaluate the efficacy of endovascular therapy for maintaining patency and preserving limbs among patients with failing infrapopliteal bypass grafts. We gathered data from a registry of catheter-based procedures for peripheral artery disease. Of 1554 arteriograms performed from 2006 to 2012, 30 patients had interventions for failing bypass vein grafts to infrapopliteal target vessels. The first intervention for each patient was used in this analysis. Duplex ultrasonography was used within 30 days after intervention and subsequently at 3- to 6-month intervals for graft surveillance. Interventions were performed for duplex ultrasonography surveillance findings in 21 patients and for symptoms of persistent or recurrent critical limb ischemia in 9 patients. Procedural techniques included cutting balloon angioplasty (83%), conventional balloon angioplasty (7%), and stent placement (10%). Procedural success was achieved in all cases. There were no procedure-related complications, amputations, or deaths within 30 days. By Kaplan-Meier analysis, 37% of the patients were free from graft restenosis at 12 months and 31% were at 24 months. Receiver-operating characteristic analysis indicated that a lesion length of 1.75 cm best predicted freedom from restenosis (C statistic: 0.74). Residual stenosis (P = 0.03), patency without reintervention (P = 0.01), and assisted patency with secondary intervention (P = 0.02) rates were superior for short lesions compared with long lesions. The cohort had acceptable rates of adverse clinical outcomes, with 96% of patients free from amputation at both 12 and 24 months; clinical outcomes were also better in patients with short lesions. In this single-center experience with endovascular therapies to treat failing infrapopliteal bypass grafts, rates of limb preservation were high, but the majority of patients developed graft restenosis within 12 months. Grafts with longer stenoses fared poorly by comparison. These data suggest that endovascular interventions to restore or prolong graft patency may be associated with maintained graft patency and that close follow-up with vascular laboratory surveillance is essential.

The effect of graft configuration on 30-day failure of infrapopliteal bypasses

Despite advances in endovascular techniques, infrapopliteal bypasses are still required for limb salvage. Short-term graft patency is an important outcome parameter reflecting technical considerations and acute graft thrombosis. Both are important prerequisites for long-term patency. In this analysis, we compared the 30-day patency of all conduit configurations for infrapopliteal bypasses. All primary infrapopliteal bypasses from the American College of Surgeons-National Surgical Quality Improvement Program database between 2005 and 2010 were divided into six groups: (1) great saphenous vein (GSV); (2) prosthetic conduit (prosthetic); (3) prosthetic conduit with a distal anastomotic venous adjunct (ADJ), such as a cuff or patch (prosthetic + ADJ); (4) composite graft of prosthetic and a vein segment (composite); (5) spliced autogenous vein (spliced vein); and (6) arm vein. Thirty-day graft failure, patient demographics, and operative details were compared among groups. A multivariate model was used for statistical analysis. A total of 5375 infrapopliteal bypasses were analyzed by conduit: GSV, 3983 (75%); prosthetic, 898 (17%); spliced vein, 160 (3%); prosthetic + ADJ, 112 (2%); arm vein, 93 (2%); and composite, 91 (2%). The difference among groups in demographics and comorbidities was not statistically significant. Perioperative mortality rates were similar among different conduits. After adjusting for sex, age, weight, race, and previous cardiac surgery, the bypass conduit had a significant independent association with 30-day graft patency (P = .006). The GSV failure rate was 7.5%. Composite had a significantly higher 30-day failure rate (15.4%, P = .006). There was no significant difference in 30-day failure rate of spliced vein (5.6%, P = .37) or arm vein (4.3%, P = .24) conduits compared with GSV. Prosthetic had significantly higher 30-day failure rate than GSV (10.5%, P = .004). The addition of adjuvant venous tissue at the distal anastomosis of prosthetic bypasses did not significantly improve their 30-day patency (failure rate of 9.8% for prosthetic + ADJ and 10.5% for prosthetic). There was no significant difference in graft patency between alternative venous conduits (arm vein/spliced vein) and prosthetic + ADJ. Venous conduits (GSV, spliced vein, arm vein) deliver the best 30-day patency for infrapopliteal bypasses, and GSV remains the most commonly used graft. Prosthetic grafts had a higher 30-day failure rate. Composite grafts should be abandoned because their early patency is not better than pure prosthetic conduits. The addition of a distal venous adjunct did not seem to improve acute prosthetic graft patency, which may reflect lack of effect on thrombogenicity rather than the myointimal hyperplastic response that effects long-term failure of infrapopliteal bypass.

Utility of direct angiosome revascularization and runoff scores in predicting outcomes in patients undergoing revascularization for critical limb ischemia

Both runoff scores and direct (DR) vs indirect revascularization (IR) according to pedal angiosomes have unclear impact on outcome for patients with critical limb ischemia (CLI). We compared DR vs IR and runoff scores in CLI patients undergoing infrapopliteal bypass for foot wounds. Patients who had tibial/pedal bypass for a foot/ankle wound from 2005-2011 were identified and operations classified as DR or IR based on wound location and bypass target. A blinded observer reviewed angiograms for an intact pedal arch and calculated standard Society for Vascular Surgery (single tibial) and modified (composite tibial) runoff scores. Comorbidities, wound characteristics, wound healing, major amputation, and overall survival were determined. A total of 106 limbs were revascularized in 97 patients; 54 limbs had DR and 52 had IR, although only 36% of wounds corresponded to a single, distinct angiosome. Wound characteristics and comorbidities were similar between groups. Mean standard (7.9 vs 7.2; P = .001) and modified (22.2 vs 20.0; P = .02) runoff scores were worse (higher number indicates worse runoff) in the IR vs DR groups; 33% had a complete pedal arch. Complete wound healing (78% vs 46%; P = .001) and time to complete healing (99 vs 195 days; P = .002) were superior with DR vs IR but were not influenced by runoff score, modified runoff score or presence of complete plantar arch. In multivariate models controlling for runoff score, DR remained a significant predictor for wound healing (odds ratio, 2.9; 95% confidence interval, 1.1-7.4; P = .028) and reduced healing time (hazard ratio, 2.1; 95% confidence interval, 1.2-3.7; P = .012). Mean amputation-free survival (75 vs 71 months for DR vs IR; P = .82) and median survival (36 vs 33 months DR vs IR; P = .22) were not different for DR vs IR. DR according to pedal angiosomes provides more efficient wound healing, but is possible in only one-half of the patients and does not affect amputation-free or overall survival. DR is associated with improved runoff scores, but current runoff scores have little clinical utility in predicting outcomes in CLI patients.

The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome

This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI). Between 2004 and 2011, patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. Angiography was used to divide the pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary end points were patency rates at 12 months, amputation-free survival at 48 months, and the rate of healing and time to healing of foot tissue loss. A total of 154 patients (75% men) with CLI underwent 167 infrapopliteal bypasses. Patients were a median age of 75 years (range, 46-96 years). Diabetic mellitus was present in 76%, chronic renal failure in 28%, and ischemic heart disease in 44%. The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264). The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.

A cost-effectiveness analysis of infrainguinal bypass in the absence of great saphenous vein conduit

Good-quality great saphenous vein (GSV) is the preferred conduit for infrainguinal surgical revascularizations, but it is not available in all patients. We sought to identify the alternative conduit that would maximize cost-effectiveness in the context of infrapopliteal bypass for critical limb ischemia and nonhealing foot wounds. A Markov model was used to create a detailed simulation of 10-year outcomes in a hypothetical Edifoligide for the Prevention of Infrainguinal Vein Graft Failure (PREVENT) III-type patient cohort undergoing infrainguinal bypass for nonhealing foot wounds. The following management options were evaluated: (1) conservative therapy (local wound care, amputation as needed); (2) primary amputation; (3) bypass with autologous alternative vein (AAV), including arm or lesser saphenous vein; (4) bypass with GSV<3 mm in diameter; (5) bypass with polytetrafluoroethylene (PTFE); (6)cryopreserved venous allograft; and (7) cryopreserved arterial allograft. Estimates of 10-year total costs were incorporated into the model. Cost-effectiveness was measured in terms of incremental United States dollars per additional year of ambulation. Bypass with AAV had the highest effectiveness as measured in median years of ambulation. After primary amputation, bypass with PTFE had the lowest total costs. With incremental cost-effectiveness ratios of $5325 and $21,228, bypass with PTFE or AAV appeared to be cost-effective alternatives to conservative therapy for nonhealing ischemic wounds. Primary amputation, GSV<3 mm, and allograft options were dominated (ie, more costly and less effective). Primary amputation was weakly dominated. Bypass with PTFE or AAV appears to be a cost-effective option for the management of critical limb ischemia and nonhealing foot wounds when good-quality GSV is not available.

Readmissions of patients with diabetes mellitus and foot ulcers after infra-popliteal bypass surgery - attacking the problem by an integrated case management model

Patients with neuroischemic diabetic foot syndrome (DFS) may need arterial revascularization, minor amputations, débridements as well as meticulous wound care. Unfortunately, postoperative outpatient care is frequently inadequate. This is especially true for Germany, where the in- and outpatient sectors are funded and managed separately, with poor communication between the two. Thus, many patients may be readmitted to the hospital following successful treatment and discharge. In an attempt to overcome these problems, we looked at whether an integrated case management (CM) system for outpatient care according to in-hospital standards might improve patients care and avoid readmissions. In addition we analyzed the length of hospital stay (LOS) as well as hospital costs. In this retrospective cohort study patients with DFS, bypass surgery and foot surgery after implementation of the CM (study group; n = 376) were compared with a matched historic control group (HCG; n = 190) including the flat rate revenues (G-DRG K01B). Following a standardized assessment, integrated trans-sectoral CM care was offered to 116 patients (CMP). The proportion of patients who were readmitted to hospital was reduced in CMP compared to HCG (8.8 vs. 16.4 %; p < 0.01), with consequent reduction of case consolidations (9.7 % versus 17.8 %, p < 0.001). Although initially, the mean LOS was higher in the CMP patients, the reduction in readmissions meant that this integrated CM program improved the hospital's economic situation. A hospital-based integrated CM system significantly reduces the hospital readmissions in patients with neuroischemic DFS following bypass surgery, with lower hospital costs.

A Novel Reverse Thermosensitive Polymer to Achieve Temporary Atraumatic Vessel Occlusion in Infra-popliteal Bypasses

ObjectiveThe study aims to assess a novel thermosensitive polymer (LeGoo®) for distal vessel control during infra-popliteal (crural/pedal) bypass surgery in severe leg ischaemia. MethodRetrospective analysis of all distal bypasses from October 2009 to February 2012. Technical success, patency, limb salvage and amputation-free survival rates were analysed. ResultsFifty-four infra-popliteal bypasses using the polymer were performed in 46 patients. The distal anastomosis was at the anterior tibial (n = 15, 28%), posterior tibial (n = 12, 22%), peroneal (n = 8, 15%), tibio-peroneal trunk (n = 8, 15%) and dorsalis pedis arteries (n = 11, 20%). Technical success was achieved in 51/54 (94.4%; failures: two inadequate haemostasis, one un-dissolved polymer). In-hospital duplex of the distal anastomosis showed a significant stenosis in two cases (4.3%). Outflow angioplasty was performed in three cases (two distal anastomotic, one run-off vessel, 5.6%). The 1-year patency rate was 76.2% (standard error (SE) 6.7%), limb salvage rate 79.3% (SE 6.7%). Amputation-free survival was 93.5% at 30 days (SE 3.6%) and 67.5% at 1 year (SE 7.5%). ConclusionThis thermosensitive polymer is a potentially safe and useful atraumatic device to achieve a blood-less distal anastomotic field in infra-popliteal bypasses. The technique avoids other potentially traumatic methods of vessel control, which may be particularly important in patients with calcified distal vessels.

Anesthesia-Based Evaluation of Outcomes of Lower-Extremity Vascular Bypass Procedures

This report examines the effects of regional versus general anesthesia for infrainguinal bypass procedures performed in the treatment of critical limb ischemia (CLI). Nonemergent infrainguinal bypass procedures for CLI (defined as rest pain or tissue loss) were identified using the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program database using International Classification of Disease, ninth edition, and Current Procedure Terminology codes. Patients were classified according to National Surgical Quality Improvement Program data as receiving either general anesthesia or regional anesthesia. The regional anesthesia group included those specified as having regional, spinal, or epidural anesthesia. Demographic, medical, risk factor, operative, and outcomes data were abstracted for the study sample. Individual outcomes were evaluated according to the following morbidity categories: wound, pulmonary, venous thromboembolic, genitourinary, cardiovascular, and operative. Length of stay, total morbidity, and mortality were also evaluated. Associations between anesthesia types and outcomes were evaluated using linear or logistic regression. A total of 5,462 inpatient hospital visits involving infrainguinal bypasses for CLI were identified. Mean patient age was 69 ± 12 years; 69% were Caucasian; and 39% were female. In all, 4,768 procedures were performed using general anesthesia and 694 with regional anesthesia. Patients receiving general anesthesia were younger and significantly more likely to have a history of smoking, previous lower-extremity bypass, previous amputation, previous stroke, and a history of a bleeding diathesis including the use of warfarin. Patients receiving regional anesthesia had a higher prevalence of chronic obstructive pulmonary disease. Tibial-level bypasses were performed in 51% of procedures, whereas 49% of procedures were popliteal-level bypasses. Cases performed using general anesthesia demonstrated a higher rate of resident involvement, need for blood transfusion, and operative time. There was no difference in the rate of popliteal-level and infrapopliteal-level bypasses between groups. Infrapopliteal bypass procedures performed using general anesthesia were more likely to involve prosthetic grafts and composite vein. Mortality occurred in 157 patients (3%). The overall morbidity rate was 37%. Mean and median lengths of stay were 7.5 days (± 8.1) and 6.0 days (Q1: 4.0, Q3: 8.0), respectively. Multivariate analyses demonstrated no significant differences by anesthesia type in the incidence of morbidity, mortality, or length of stay. These results provide no evidence to support the systematic avoidance of general anesthesia for lower-extremity bypass procedures. These data suggest that anesthetic choice should be governed by local expertise and practice patterns.

The impact of endovascular procedures on fellowship training in lower extremity revascularization

The introduction of endovascular aneurysm repair has resulted in a decline in open abdominal aortic aneurysm repairs performed by vascular residents. The purpose of this study was to evaluate if a similar trend has occurred with open lower extremity revascularization procedures, with increased endovascular procedures producing a decrease in the number of open lower extremity revascularizations. Furthermore, this study evaluates the effect of endovascular procedure volume on the frequency of subtypes of open lower extremity procedures performed. The total number of vascular procedures, lower extremity bypasses, and endovascular interventions from 2000 to 2010 were analyzed from case logs of vascular residents as reported by the Accreditation Council for Graduate Medical Education. The average number of cases performed by vascular residents has increased by 150% from 463.9 in 2000 to 1168 in 2009, due to the increased number of endovascular procedures. The average number of endovascular revascularizations has increased by 317% from 40.5 performed in 2000 to 168.9 in 2009. Femoral-popliteal bypasses have increased in frequency by 27% whereas the number of infrapopliteal bypass has remained unchanged. The largest difference is seen in femoral endarterectomies with a 234% increase from 3.2 per resident in 2001 to 10.7 per resident in 2010. Comparison of the proportion of femoral-popliteal and tibioperoneal interventions performed by angioplasty or bypass after 2007 revealed that endovascular interventions comprise 50% of procedures in the femoral-popliteal distribution, whereas 65% of infrapopliteal interventions are still performed using open techniques. The number of procedures performed during vascular residency has dramatically increased over the last decade secondary to the increased number of endovascular procedures. The average vascular surgery resident's open operative experience has been stable over the last 10 years, despite the increasing endovascular case volume. Residents perform femoral endarterectomy with increasing frequency, perhaps representing an increasing volume of hybrid procedures. Gaps in information available for evaluating resident training remain a significant obstacle. Moving forward, revision of the current reporting system to a format that more accurately reflects resident experience would be beneficial.

Resultados de la cirugía de revascularización infragenicular mediante bypass con venas braquiales

Introduction We present our results on infragenicular surgical revascularisation with arm vein bypass. Patients and methods A retrospective study of 30 patients with infragenicular arm vein bypass. Results The 30 day patency and limb salvage rate was 90 ± 5.5%. The 1 year patency rates were 54 ± 9.5% (primary, primary assisted and secondary). The 2 year rates were 45 ± 9.8% (primary and primary assisted) and 49 ± 9.7% (secondary). The limb salvage rate was 54 ± 9.5% (1 year) and 45 ± 9.8% (2 years). Up to 70 per cent of the patients did not have any perioperative complications. Conclusions In infrapopliteal bypass surgery without an adequate great saphenous vein, the use of arm veins should be considered as a good therapeutic option.

Distal versus Ultradistal Bypass Grafts: Amputation-free Survival and Patency Rates in Patients with Critical Leg Ischaemia

Objectives Compare the outcome of distal (bypass to the crural arteries) versus ultradistal (bypass to the pedal arteries) bypasses in patients with critical leg ischaemia (CLI). Design Retrospective analysis of prospectively collected data of patients with CLI undergoing infra-popliteal bypass surgery is performed. Materials and Methods Patients undergoing infra-popliteal bypass at a single institution between 2004 and 2010 are included. Patency rates at 1-year and amputation-free survival at 12 and 48 months are analysed. Results Two hundred and thirty bypasses were performed in 209 consecutive patients (156 men, median age; 76 years, range; 19–96 years). One hundred and seventy nine (78%) bypass were classified as distal and 51 (22%) as ultradistal. The incidence of diabetes mellitus was significantly higher in the ultradistal group ( p = 0.0025). At 1-year, the distal group primary, assisted-primary and secondary patency rates were 61.7%, 83.1% and 87.4% compared to 61.9%, 87.4% and 87.4% in the ultradistal group respectively. Amputation-free survival at 12 and 48 months was 82.9% and 61.5% in the distal group compared to 83.0% and 64.9% in the ultradistal group. Conclusions This study show that both distal and ultradistal bypass have comparable outcome regardless of the co-morbidities. The authors believe that elderly patients should be offered ultradistal bypass if indicated to avoid major amputation.