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Suprainguinal Inflow For Distal Bypasses Have Acceptable Patency And Limb Salvage Rates
Molly Ratner1, Heepeel Chang, MD2, Mikel Sadek, MD1, Jeffrey J. Siracuse, MD MBA3, Thomas Maldonado, MD1, Neal Cayne1, Glenn Jacobowitz, MD1, Caron Rockman, MD1, Karan Garg, MD1.
1New York University Langone Hospital, New York, NY, USA, 2Westchester Medical Center, New York, NY, USA, 3Boston Medical Center, Boston, MA, USA.

OBJECTIVES: There is a paucity of data evaluating outcomes of lower extremity bypass (LEB) using supra-inguinal inflow for revascularization of infra-inguinal vessels. The purpose of this study is to report outcomes after LEB originating from aortoiliac arteries to infra-femoral targets.
METHODS: The Vascular Quality Initiative database (2003-2020) was queried for patients undergoing LEB from the aortoiliac arteries to the popliteal and tibial arteries. Patients were stratified into three cohorts based on outflow targets (above-knee popliteal, below-knee popliteal and tibial arteries). Perioperative and 1-year outcomes including primary patency, amputation-free survival, and major adverse limb events (MALEs) were compared. A Cox proportional hazards model was used to estimate the independent prognostic factors of outcomes. RESULTS: Of 403 LEBs, 389 (96.5%) originated from the external iliac artery, while the remaining used the aorta or common iliac artery as inflow. In terms of the distal target, the above knee popliteal was used in 116 (28.8%), the below knee popliteal in 151 (27.5%), and tibial vessels in 136 (43.7%) cases. Below-knee popliteal and tibial bypasses, compared to above knee popliteal bypasses, were more commonly performed in patients with chronic limb-threatening ischemia (70% and 70% vs 48%; P < .001). Vein conduit was more often used for tibial bypass than for above- and below-knee popliteal bypasses (46% vs 22% and 17%; P < .001). In the perioperative period, below-knee popliteal and tibial bypass patients had higher reoperation rates (17% and 14% vs 5%; P = .015) and lower primary patency (91% and 90% vs 96%; P = .044) than above-knee bypass patients. At 1 year, compared with above-knee popliteal bypasses, below-knee and tibial bypasses demonstrated lower primary patency (60.9% and 62.3% vs 83.3%; P < .001; Fig 1) and amputation-free survival (69.1% and 66.4% vs 79.4%; P = .0223), but freedom from MALE was similar (87.2% and 82.8% vs 90.9%; P = .0585). On multivariable analysis, compared with above-knee popliteal bypasses, tibial bypasses were independently associated with increased loss of primary patency (hazard ratio 1.9, 95% confidence interval, 1.03-3.51, p = .039).
CONCLUSIONS: LEB with supra-inguinal inflow appear to have acceptable rates of 1-year patency and limb salvage in patients at high risk of bypass failure. Tibial outflow target was independently associated with worse primary patency but not with MALE.
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