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Redo Infra-inguinal Bypass: A Single Institution Experience Over Two Decades
Taleen A. MacArthur, MD, Fahad Shuja, MBBS, Jill J. Colglazier, MD, Randall R. DeMartino, MD, MS, Todd E. Rasmussen, MD, Melinda S. Schaller, MD, Lindsey Young, MD, Manju Kalra, MBBS.
Mayo Clinic, Rochester, MN, USA.
OBJECTIVES: The BEST CLI trial has resulted in rejuvenating interest in lower extremity bypass, however, data on outcomes of redo procedures is scarce. The aim of this study was to evaluate long term outcomes following redo infrainguinal bypasses.
METHODS: Data from consecutive patients who underwent redo infra-inguinal bypass after prior infrainguinal bypass failure between January 2000 and December 2022 were retrospectively reviewed. Primary endpoints were primary (PP), primary assisted (PAP), secondary (SP) graft patency and major limb amputation (MLA). Results are presented as medians with quartiles [Q1, Q3]. Data was analyzed using GraphPad Prism (Graphpad, Boston, MA).
RESULTS:There were 151 bypasses in 148 patients (64.2% males, age 69 years), 12% with Rutherford III, 68.8% with IV/V chronic ischemia, 8.6% with acute ischemia, 3.8% with graft infection/ pseudoaneurysm. Fifteen % of patients had failed > 1 prior bypass and 14% had endovascular intervention after bypass failure. Comorbidities included hypertension (84.7%), DM (34.4%), CAD (51.6%), ESRD (5.3%), and 23% were active smokers. Inflow arteries were common /profunda femoral in 85.4% and SFA/popliteal in14.5%. Outflow targets included above and below knee popliteal in 2.6% and 24.5% of bypasses, tibioperoneal trunk 10.5%, tibial 59.6% and pedal 2.6%. Conduits used were single segment great saphenous (SSGSV, 36.1%), arm vein (AV, 15.7%), composite vein (CV, 47.2%), ePTFE (25.9%) and cryopreserved venous allograft (1.3%). Venous conduits were used in 84.1% of tibial, ePTFE in 61.5% of popliteal targets. Median follow up was 22 [7, 93] months. PP, PAP, freedom from MLA and overall survival at 1 and 5 years were 65%, 68%, 91%, 96%, and 46%, 48%, 79%, 86%, respectively. SP was achieved in only 3 bypasses. During follow-up 79 patients died; 23 MLAs were performed, with mean time to amputation of 38.5 months and no significant difference between vein (14.8%) and prosthetic (17.9%) conduits, p=0.61. Amputation free survival at 5-, and 10 years was 78.5% and 64.2%, respectively (Figure).
CONCLUSIONS: Although challenging, redo infrainguinal bypasses are associated with very acceptable outcomes in terms of limb salvage, even in the long term. These data should serve as baseline for comparison with endovascular interventions following bypass failure.
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