Lower Extremity Bypass Grafts Research Articles

Predicting future occlusion or stenosis of lower extremity bypass grafts using artificial intelligence to simultaneously analyze all flow velocities collected in current and previous ultrasound examinations

ObjectiveRoutine surveillance with duplex ultrasound (DUS) examination is recommended after femoral-popliteal and femoral-tibial-pedal vein bypass grafts with various intervals postoperatively. The presently used methodology to analyze bypass graft DUS examination does not use all the available data and has been shown to have a significant rate for missing impending bypass graft failure. The objective of this research is to investigate recurrent neural networks (RNNs) to predict future bypass graft occlusion or stenosis. MethodsThis study includes DUS examinations of 663 patients who had bypass graft operations done between January 2009 and June 2022. Only examinations without missing values were included. We developed two RNNs (a bidirectional long short-term memory unit and a bidirectional gated recurrent unit) to predict bypass graft occlusion and stenosis based on peak systolic velocities collected in the 2 to 5 previous DUS examinations. We excluded the examinations with missing values and split our data into training and test sets. Then, we applied 10-fold cross-validation on training to optimize the hyperparameters and compared models using the test data. ResultsThe bidirectional long short-term memory unit model can gain an overall sensitivity of 0.939, specificity of 0.963, and area under the curve of 0.950 on the prediction of bypass graft occlusion, and an overall sensitivity of 0.915, specificity of 0.909, and area under the curve of 0.912 predicting the development of a future critical stenosis. The results on different bypass types show that the system performs differently on different types. The results on subcohorts based on gender, smoking status, and comorbidities show that the performance on current smokers is lower than the never smoker. ConclusionsWe found that RNNs can gain good sensitivity, specificity, and accuracy for the detection of impending bypass graft occlusion or the future development of a critical bypass graft stenosis using all the available peak systolic velocity data in the present and previous bypass graft DUS examinations. Integrating clinical data, including demographics, social determinants, medication, and other risk factors, together with the DUS examination may result in further improvements. Clinical RelevanceDetecting bypass graft failure before it occurs is important clinically to prevent amputations, salvage limbs, and save lives. Current methods evaluating screening duplex ultrasound examinations have a significant failure rate for detecting a bypass graft at risk for failure. Artificial intelligence using recurrent neural networks has the potential to improve the detection of at-risk bypass graft before they fail. Additionally, artificial intelligence is in the news and is being applied to many fields. Vascular surgeons need to know its potential to improve vascular outcomes.

Outcomes of Arterial Grafts for the Reconstruction of Military Lower Extremity Arterial Injuries

Lower extremity (LE) arterial injuries are common in military casualties and limb salvage is a primary goal. Bypass grafts are the most common reconstructions; however, their specific outcomes are largely unreported. We sought to describe the outcomes of LE arterial grafts among combat casualties and their association with limb loss. Retrospective cohort study of 2004-2012 Iraq/Afghanistan casualties with LE arterial injury undergoing bypass graft from a database containing follow-up until amputation, death, or military discharge. Primary outcome was composite graft complications (GC-thrombosis, stenosis, pseudoaneurysm, blowout, and/or arteriovenous fistula). Two hundred and twenty-two grafts were included (99 femoral, 73 popliteal, 48 tibial). 56 (26%) had at least one GC; thrombosis was most common in femoral, stenosis most common in popliteal and tibial. GC was not associated with graft level but was associated with synthetic conduit (P = 0.01) and trended towards an association with multiple-level arterial injuries (P = 0.07). Four of eight (50%) synthetic grafts had amputations, all within 72h. Two of the eight synthetic grafts thrombosed, and both limbs were amputated. There were 52 total amputations. Amputation was performed in 13 (23%) of limbs with a GC and 24% of those without (P = 0.93) Overall, 24 (11%) of grafts thrombosed, 16 within 48h and 13 (25%) in limbs undergoing amputation (P = 0.001 for association of thrombosis with amputation). GC are common among LE bypass grafts in combat casualties but are not associated with limb loss. Thrombosis is predominantly early and is associated with amputation. Closer attention to ensuring early patency may improve limb salvage.

Effect of occult malignancy on femoropopliteal bypass graft thrombosis

ObjectiveThe presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, before a formal diagnosis of cancer. To the best of our knowledge, this increase in thrombotic risk has not been studied in patients with lower extremity bypass grafts. In the present study, we aimed to determine the effect of occult cancer on femoropopliteal bypass patency. MethodsA retrospective review of femoropopliteal bypass procedures completed from 2001 to 2018 was performed. International Classification of Diseases, 9th and 10th revision, codes corresponding to breast, lung, prostate, colorectal, skin, brain, and hematologic cancer were used to identify patients who had had occult cancer. Occult cancer was defined as cancer diagnosed within ≤1 year after the bypass procedure. The demographics, comorbidities, bypass configuration and conduit, 1-month, 3-month, 6-month, and 1-year occlusion rates, major adverse limb events, and mortality rates were analyzed. Statistical analysis included t tests, χ2 tests, and Cox regression analysis. ResultsA total of 621 procedures in 517 patients met the inclusion criteria. Of the 621 procedures, 36 (5.8%) were classified as procedures in patients with occult cancer. The patients with occult cancer had had higher occlusion rates at 3 months (27.8% vs 8.0%; P < .001), 6 months (30.5% vs 15.1%; P < .01), and 1 year (44.4% vs 19.8%; P < .001). In Cox regression analysis for bypass thrombosis at 1 year, the only significant predictors were occult cancer (hazard ratio [HR], 2.03; P = .01), below-the-knee distal target (HR, 1.88; P < .01), and a compromised conduit (HR, 2.14; P < .001). ConclusionsWe found an increase in bypass graft thrombosis rates in patients who had undergone femoropopliteal bypass who had had occult cancer. Thrombosis of the graft within 1 year postoperatively might be a sign of occult cancer.

The Impact of Occult Cancer on Lower Extremity Femoral-Popliteal Bypass Reintervention Rates

Recent studies have demonstrated that the presence of cancer increases arterial thromboembolic events, specifically myocardial infarction and stroke, up to 150 days before a formal diagnosis of cancer. This increase in thrombotic risk for patients with occult cancer has never been studied in patients with lower extremity bypass grafts for peripheral arterial disease. This study aimed to determine the impact of occult cancer on femoral-popliteal bypass reintervention rates.

Revascularization limb salvage in chronic limb-threatening ischemia: does open surgery still the best option in the era of endovascular therapy?

Introduction: Chronic limb-threatening ischemia (CLTI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels who suffered from diabetes mellitus type 2, and also associated with physical, as well as psychosocial, consequences such as amputation and depression. Successful revascularization decreases the major amputation rate in patients with CLTI. The efficacy of peripheral bypass grafts and percutaneous transluminal angioplasty in accomplishing limb salvage has been recognized.Case Description: A 42-year-old man came to the RSUZA emergency room with chief complaints claudication above the right thigh and continuous pain (rest pain) at the right lower extremity since 9 months ago. History of finger amputation 2nd, 3rd and 4th right foot since 10 months ago at local hospital, and now there are necrotic wounds on his toes. Patients suffered from type 2 diabetes mellitus and have bad habits such as smoking 3 packs a day all the time. Physical examination has a wound in the lower leg area of more than 10 cm x 8 cm. Right ankle-brachial index (ABI) 0.6 and left ABI 1.3. CT-angiography (CTA) shows infra inguinal type D TASC II classification. A revascularization procedure is performed to salvage the limb with the right femoro-popliteal bypass technique with graft R-SVG and debridement in the right lower leg area so that chronic right lower limb ischemia can be overcome. Systemic heparinization was given post operatively and complaints of pain in the right lower limb begin to disappear. Patient was discharged on the 5th day of treatment with good results.Conclusion: Open surgical bypass continues to be a primary treatment of choice, durable approach in a significant proportion of patients. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5mm diameter.Â

IP125. Moraxella Catarrhalis Bacteremia Associated With Lower Extremity Bypass Graft Infection: Case Report and Review of Literature

IP125. Moraxella Catarrhalis Bacteremia Associated With Lower Extremity Bypass Graft Infection: Case Report and Review of Literature

Surgical Principles for the Management of Peripheral Graft Infections

Prosthetic graft infections remain one of the most significant complications encountered by vascular surgeons given the high rate of morbidity and limb loss. Graft infections involving the lower extremity have a reported incidence of 2 to 6%. Presentation can include an indolent infection, septic shock, or frank hemorrhage. The goals of therapy are minimizing morbidity and mortality, preventing recurrent infection, and limb salvage. The gold standard in management is complete graft excision; however, this may not always be feasible or necessary. Various techniques such as partial preservation with concomitant revascularization may be appropriate in selected circumstances. A thorough understanding of the pathophysiology, extent of infection, and the patient’s overall clinical picture are necessary so that a patient-specific approach can be implemented. This review contains 4 figures, 1 table, and 31 references. Keywords: cryopreserved cadaveric graft, extracavitary graft, graft excision, graft infection, graft preservation, lower-extremity bypass graft, lateral femoral bypass, prosthetic vascular graft

Coronary Drug-Eluting Stents for the Treatment of Threatened Lower Extremity Bypass Grafts: A Single-Institution Case Series

Coronary Drug-Eluting Stents for the Treatment of Threatened Lower Extremity Bypass Grafts: A Single-Institution Case Series

IP225. Coronary Drug-Eluting Stents for the Treatment of Threatened Lower Extremity Bypass Grafts: A Single-Institution Case Series

IP225. Coronary Drug-Eluting Stents for the Treatment of Threatened Lower Extremity Bypass Grafts: A Single-Institution Case Series

Endovascular Reintervention for Failing Infrainguinal Bypass Grafts

Patients with lower extremity bypass grafts that develop stenosis commonly undergo endovascular treatment (EVT) procedures. This study was performed to evaluate the outcomes of EVT procedures for infrainguinal grafts with bypass at risk (BAR). We performed a retrospective review of 24 grafts in 22 patients from July 2010 to June 2016. The demographic information of the patients and the characteristics of lesions were examined, and the outcomes with regard to the patency and survival rates were calculated. Twenty-four grafts were evaluated; the initial technical success rate of EVT procedure was 91.7%. Sixteen of 24 bypass grafts (66.7%) required multiple EVT procedures due to graft restenosis. Inflow vessels from the superficial femoral artery were associated with significantly higher rates of single EVT procedures (P=0.0206). At 2 years, the primary, assisted primary, and secondary patency rates were 30.3%, 69.5%, and 78.0%, respectively. The EVT procedure is one of the treatment options for the treatment of grafts with BAR and might be associated with an acceptable medium-term patency rate.

Management of Critical Limb Ischemia

Critical limb ischemia (CLI) is a clinical syndrome of ischemic pain at rest or tissue loss, such as nonhealing ulcers or gangrene, related to peripheral artery disease. CLI has a high short-term risk of limb loss and cardiovascular events. Noninvasive or invasive angiography help determine the feasibility and approach to arterial revascularization. An endovascular-first approach is often advocated based on a lower procedural risk; however, specific patterns of disease may be best treated by open surgical revascularization. Balloon angioplasty and stenting form the backbone of endovascular techniques, with drug-eluting stents and drug-coated balloons offering low rates of repeat revascularization. Combined antegrade and retrograde approaches can increase success in long total occlusions. Below the knee, angiosome-directed angioplasty may lead to greater wound healing, but failing this, any straight-line flow into the foot is pursued. Hybrid surgical techniques such as iliac stenting and common femoral endarterectomy are commonly used to reduce operative risk. Lower extremity bypass grafting is most successful with a good quality, long, single-segment autogenous vein of at least 3.5-mm diameter. Minor amputations are often required for tissue loss as a part of the treatment strategy. Major amputations (at or above the ankle) limit functional independence, and their prevention is a key goal of CLI therapy. Medical therapy after revascularization targets risk factors for atherosclerosis and assesses wound healing and new or recurrent flow-limiting disease. The ongoing National Institutes of Health-sponsored Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) study is a randomized trial of the contemporary endovascular versus open surgical techniques in patients with CLI.

Open surgical revision provides a more durable repair than endovascular treatment for unfavorable vein graft lesions

Lower extremity bypass grafts that develop stenoses are commonly treated with either open surgical or endovascular revision. Vein graft stenoses with unfavorable lesions (multiple lesions, lesions >2 cm in length, lesions in grafts <3 months old, lesions in grafts <3 mm in diameter) fare worse than those with favorable lesions when treated with endovascular therapy. However, it is not known if unfavorable lesions fare better with surgical revision than with endovascular treatment or than favorable lesions treated with surgery. We performed a retrospective review of 175 vein graft revisions performed at a single institution from 2000 to 2010. Characteristics of lesions treated with surgical and endovascular revision were identified. Cox proportional hazard models were used to identify predictors of revision failure (restenosis >75%, revision, or amputation). Ninety-one failing vein grafts (52%) were treated with surgical revision and 84 with endovascular treatment (48%), with a median follow-up of 30 months. Favorable lesions fared better than unfavorable lesions after endovascular treatment, with 12-month freedom from failure of 59% vs 34% (P < .01), but not after surgical revision (66% vs 62%; P = .90). Unfavorable lesions had better freedom from failure after surgery than endovascular treatment (62% vs 34%; P < .01), and results in favorable lesions were similar (66% vs 59%; P = .57). For the treatment of failing vein grafts, endovascular therapy appears adequate for favorable lesions and surgical revision is more durable for unfavorable lesions.

Use of an Anastomotic Coupling Device for the Creation of Spliced Autogenous Grafts in Lower Extremity Revascularization.

Despite a recent rise in popularity of endovascular techniques, open bypass surgery is still required for treating many lower extremity vascular lesions. Greater saphenous vein (GSV) of adequate length and caliber for successful infrainguinal lower extremity bypass is unavailable in 15% to 45% of patients. To overcome limitations imposed by absent vein due to prior use, short vessel length, or sclerotic segments, both alternate (ie, basilic and cephalic) and GSV conduits may be "spliced" together in series via venovenostomy. Although vascular surgeons typically perform a hand-sewn venovenostomy, device-based venous coupling has been performed by plastic surgeons for many years. We therefore sought to review our experience with venous coupling for segmental lower extremity bypass graft assembly. A retrospective review was performed in all patients who underwent lower extremity revascularization using autogenous vein grafts spliced together with the Synovis (Birmingham, Alabama) anastomotic coupler at a single institution over a 5-year period. The anastomotic coupler device was used on 5 patients for 7 venovenostomies. The mean age of patients was 66 years, and the mean follow-up period was 751 days. Two patients were lost to follow-up, while 2 other patients died of causes unrelated to their lower extremity bypass. The average time to perform venovenostomy was 3 minutes. Three patients developed stenosis of their composite graft at a site other than the venovenostomy, who were successfully treated with either angioplasty or bypass revision. One-year primary and primary-assisted patency rates were 50% and 75%, respectively. Given the known benefits of the anastomotic coupling device when used for venous anastomoses in microsurgical reconstruction, transition of this device to the vascular surgery realm represents a logical progression. Although small, our series demonstrates that the anastomotic coupler can successfully be used for the formation of spliced autogenous grafts for lower extremity revascularization in the absence of adequate GSV.

Balloon angioplasty for revision of failing lower extremity bypass grafts

The aim of this study was to evaluate the efficacy and safety of balloon angioplasty as the primary method of intervention in patients with color duplex ultrasound documented failing bypass grafts and to determine factors that may affect the patency of lower extremity bypass grafts revised by percutaneous transluminal angioplasty (PTA). All consecutive patients who underwent lower extremity bypass grafts from January 2009 to December 2013 were enrolled in a graft surveillance program. Patients identified as having failing grafts underwent arteriography to confirm the diagnosis with a view to concomitant treatment of the lesion using balloon angioplasty. Procedural success was defined as <30% residual stenosis. Treatment failure was defined as target lesion restenosis or graft occlusion. Descriptive and life-table analyses were performed. PTA was used to revise 96 failing grafts in 90 patients. Mean age was 65.8 years (range, 50-88 years), 64% were male, and 66% were symptomatic. Mean follow-up was 18.5 months (range, 3-24 months). Twenty-four grafts (25%) underwent repeat angioplasty for restenosis. Grafts with multiple lesions (P = .009) and grafts aged <6 months from the index operation (P = .004) were the only graft-related variables that showed a significant effect on the longevity of the endovascular revision. The PTA-revised grafts had primary, assisted primary, and secondary patency rates of 56.9%, 83.2%, and 90%, respectively, at 2 years. Primary balloon angioplasty of failing lower extremity bypass grafts, notwithstanding the higher restenosis rate and the need for reintervention, appears to be safe and is associated with acceptable early and medium-term patency rates. Grafts with multiple lesions and those revised ≤6 months of the index operation showed a significant association with the need for a second revision at the same site.

Pseudoaneurysm in a Bypass Graft

Sometimes a routine surveillance graft scan discloses something not so routine: in this case, giant pseudoaneurysms in the midsection of a lower-extremity bypass graft. This case report details a complication of cryopreserved vein grafts, underscoring the importance of routine surveillance imaging. It also illustrates adverse patient consequences that occur from a misdiagnosis with ultrasonography and demonstrates the critical role of the vascular sonographer in an integrated patient care team.

Endovascular Recanalization of Native Chronic Total Occlusions in Patients with Failed Lower-Extremity Bypass Grafts

PurposeTo investigate the feasibility, safety, and outcome of endovascular recanalization of native chronic total occlusions (CTOs) in patients with failed lower-extremity bypass grafts. Materials and MethodsRetrospective review of 19 limbs in 18 patients with failed lower-extremity bypass grafts that underwent recanalization of native arterial occlusions between February 2009 and April 2013 was performed. Nine of the limbs presented with acute ischemia and 10 presented with chronic ischemia, including eight with critical limb ischemia and two with disabling claudication. ResultsThe mean patency of the failed bypass grafts (63% venous) was 27 months. All limbs had Transatlantic Inter-Society Consensus class D lesions involving the native circulation. Technical success of the endovascular recanalization procedure was achieved in all but one limb (95%). The mean ankle brachial indices before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 64 weeks, and two patients were lost to follow-up. Primary patency rates at 3, 6, and 12 months were 87%, 48%, and 16%, respectively. Successful secondary procedures were performed in seven patients, with secondary patency rates at 3, 6, and 12 months of 88%, 73%, and 44%, respectively. Limb salvage rates at 12 and 24 months were 94% and 65%, and amputation-free survival rates at 12 and 24 months were 87% and 60%, respectively. ConclusionsEndovascular recanalization of native CTOs in patients with failed lower-extremity bypass grafts is technically feasible and safe and results in acceptable limb salvage.

Defining utility and predicting outcome of cadaveric lower extremity bypass grafts in patients with critical limb ischemia

Despite poor long-term patency, acceptable limb salvage has been reported with cryopreserved saphenous vein bypass (CVB) for various indications. However, utility of CVB in patients with critical limb ischemia (CLI) remains undefined. The purpose of this analysis was to determine the role of CVB in CLI patients and to identify predictors of successful outcomes. A retrospective review of all lower extremity bypass (LEB) procedures at a single institution was completed, and CVB in CLI patients were further analyzed. The primary end point was amputation-free survival. Secondary end points included primary patency and limb salvage. Life tables were used to estimate occurrence of end points. Cox regression analysis was used to determine predictors of limb salvage. From 2000 to 2012, 1059 patients underwent LEB for various indications, of whom 81 received CVB for either ischemic rest pain or tissue loss. Mean age (± standard deviation) was 66 ± 10 years (male, 51%; diabetes, 51%; hemodialysis dependence, 12%), and 73% (n = 59) had history of failed ipsilateral LEB or endovascular intervention. None had sufficient autogenous conduit for even composite vein bypass. Infrainguinal CVB (infrapopliteal target, 96%; n = 78) was completed for multiple indications including Rutherford class 4 (42%; n = 34), class 5 (40%; n = 32), and class 6 (18%; n = 15). Eleven (14%) had CLI and concomitant graft infection (n = 8) or acute on chronic ischemia (n = 3). Intraoperative adjuncts (eg, profundaplasty, suprainguinal stent or bypass) were completed in 49% (n = 40) of cases. Complications occurred in 36% (n = 29), with 30-day mortality of 4% (n = 3). Median follow-up for CLI patients was 11.8 (interquartile range, 0.4-28.4) months with corresponding 1- and 3-year actuarial estimated survival (± standard error mean) of 84% ± 4% and 62% ± 6%. Primary patency of CVB for CLI was 27% ± 6% and 17% ± 6% at 1 and 3 years, respectively. Amputation-free survival was 43% ± 6% and 23% ± 6% at 1 and 3 years, respectively, and significantly higher for rest pain (59% ± 9%, 36% ± 10%) compared with tissue loss (31% ± 7%, 14% ± 7%; log-rank, P = .04). Freedom from major amputation after CVB for CLI was 57% ± 6% and 43% ± 7% at 1 and 3 years. Multivariable predictors of limb salvage for the CVB CLI cohort included postoperative warfarin (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.2-0.8), dyslipidemia (HR, 0.4; 95% CI, 0.2-0.9), and rest pain (HR, 0.4; 95% CI, 0.2-0.9). Predictors of major amputation included graft infection (HR, 3.1; 95% CI, 1.1-9.0). In CLI patients with no autologous conduit and prior failed infrainguinal bypass, CVB outcomes are disappointing. CVB performs best in patients with rest pain, particularly those who can be anticoagulated with warfarin. However, it may be an acceptable option in patients with minor tissue loss or concurrent graft infection, but consideration should be weighed against the known natural history of nonrevascularized CLI and nonbiologic conduit alternatives, given potential cost implications.

Vein graft failure

After the creation of an autogenous lower extremity bypass graft, the vein must undergo a series of dynamic structural changes to stabilize the arterial hemodynamic forces. These changes, which are commonly referred to as remodeling, include an inflammatory response, the development of a neointima, matrix turnover, and cellular proliferation and apoptosis. The sum total of these processes results in dramatic alterations in the physical and biomechanical attributes of the arterialized vein. The most clinically obvious and easily measured of these is lumen remodeling of the graft. However, although somewhat less precise, wall thickness, matrix composition, and endothelial changes can be measured in vivo within the healing vein graft. Recent translational work has demonstrated the clinical relevance of remodeling as it relates to vein graft patency and the systemic factors influencing it. By correlating histologic and molecular changes in the vein, insights into potential therapeutic strategies to prevent bypass failure and areas for future investigation are explored.

Predictors of Major Amputation With Patent Bypass Grafts

Despite patent bypass grafts, some patients receive major amputations (MA). We analyzed the frequency and predictive factors leading to MA in the presence of patent lower extremity bypass grafts (LEB). Data from PREVENT III, a large prospective randomized trial of 1404 patients who underwent LEB for critical limb ischemia (CLI) was queried for outcomes. The primary endpoint was MA with patent (PMA) or occluded (OMA) LEB. Variables identified on univariate analysis (inclusion threshold P < .08) were included in a multivariable logistic regression model to identify independent predictors. Of 1404 LEB patients, 162 (11.5%) had MA, 89 (6.3%) with patent and 73 (5.2%) with occluded LEB. For PMA, 21 (23.6%) had critical graft stenosis, of which 17 (81.0%) underwent revision, with mean time to revision of 50.76 days (SD ± 55.49). Minority race (OR, 2.69; CI, 1.28-5.66; P = .0092), diabetes (OR, 4.14; CI, 1.20-14.24; P = .025), lower baseline activity score (OR, 1.92; CI, 1.24-2.98; P = .0036), and negative change in 3-month activity (OR, 1.61; CI, 1.22-2.13; P = .0007) were predictors for PMA, while tissue loss was not predictive (OR, 2.32; CI, 0.66-8.08; P = .19). For OMA, 64 (87.7%) had critical graft stenosis but only 35 (54.7%) underwent revision, with mean time to revision of 76.11 days (SD ± 80.14) and mean time to MA of 107.37 days (SD ± 103.39). PMA patients had lower rates of graft stenosis, but were revised earlier than their OMA counterparts. Non-graft-related factors (demographic and functional activity) also influenced PMA. Further investigation into PMA may optimize treatment decisions.

8:24 AM Abstract No. 15 - Limb salvage after endovascular recanalization of native arterial occlusions in patients with failed lower extremity bypass grafts

Purpose Failed lower extremity bypass in patients with critical limb ischemia carries a high rate of amputation. Percutaneous revascularization of the native arterial occlusion can be performed as an alternative to redo bypass in patients who are poor surgical candidates. We set forth to investigate the feasibility, safety, and outcome of endovascular recanalization of chronic native occlusions in patients with failed bypass grafts. Materials and Methods We performed a retrospective review of 15 patients with failed lower extremity bypass who underwent recanalization of their native arterial occlusions between February 2009 and August 2012. Demographic, clinical, procedural and follow-up data were collected. Technical success was defined as the ability to recanalize the occlusion and restore flow with Results Fifteen lower extremities were treated in 15 patients (7 male) with a mean age of 68 years. The mean patency of the failed bypass grafts (53% venous, 47% prosthetic) was 23.4 months. All patients had TASC C or D lesions of the native circulation. Technical success of the endovascular procedure was achieved in all but one patient (93%) with the majority undergoing subintimal recanalization. Retrograde recanalization was required in 3 patients using a transpedal or transgraft approach. Stents were placed in all patients. The mean ABIs before and after treatment were 0.34 and 0.73, respectively. There were no major complications or emergency amputations. Mean patient follow-up was 13.8 months. The mean time to PTA failure was 6.1 months. Primary patency at 3, 6 and 12 months was 78%, 47%, and 16%. Successful secondary procedures were performed in 5 patients to recanalize restenotic or reoccluded lesions with secondary patency at 3, 6 and 12 months of 85%, 46%, and 17%. Limb salvage at 6, 12 and 24 months was 93%, 93%, and 62%. Amputation-free survival at 6, 12 and 24 months was 85%, 85% and 57%. Conclusion Endovascular recanalization of native arterial occlusions in patients with failed lower extremity bypass grafts is technically feasible, safe and results in acceptable limb salvage.