Strategy of Revascularization for Critical Limb Ischemia Due to Infragenicular Lesions—Which Should Be Selected Firstly, Bypass Surgery or Endovascular Therapy?

Abstract

Background and Objectives:In patients with peripheral arterial diseases (PADs) due to infra-popliteal (below the knee; BTK) lesions, we often encounter situations requiring the immediate selection of either of two revascularization methods, namely bypass surgery or endovascular therapy (EVT). However, the question of whether endovascular or surgical revascularization should be performed initially for critical limb ischemia (CLI) patients with BTK lesions has not been clarified. To assess the efficacy and durability of EVT or bypass as a first approach, we evaluated the short-and mid-term outcomes of the first revascularizations achieved using EVT (EVT First Group; EVT-first) compared with bypass (Bypass First Group; Bypass-first). To verify the validity of each initial revascularization, we explored factors influencing overall survival (OS) rates using multivariate analyses. Methods: A total of 169 consecutive BTK revascularization procedures (150 patients) for CLI conducted at our facility between November 2006 and July 2012 were analyzed. Patients undergoing revascularization were divided into two groups (EVT-first or Bypass-first), with 102 patients undergoing endovascular therapy first (EVT-first) and 51 undergoing bypass surgery first (Bypass-first). No statistically significant differences were noted between the two groups with respect to preoperative background including age, gender, and cardiovascular risk factors (hypertension, diabetes, hyperlipidemia, coronary arterial disease (CAD), chronic heart failure (CHF), cerebrovascular disease, and hemodialysis). Technical success was defined as a single straight-line flow to the ankle after completion angiography of the first revascularization method. Hemodynamic success was defined as a postoperative skin perfusion pressure of the foot exceeding 40 mmHg. Results:The average age of patients was 76.0 years (range, 46-98 years; 65 men and 37 women) and 72.3 years (range, 43-93 years; 35 men and 13 women) in the EVT-first and Bypass-first groups, respectively. Patient follow-up ranged from 1 to 50 months (mean, 15 months). Respective technical and hemodynamic success rates were 96.2% and 66.7% for EVTfirst and 100% and 94% for Bypass-first, respectively. Treatment was required an average of 1.5 times for EVT-first and 1.2 times for Bypass-first. Respective rates for other factors examined in the EVT-first and the Bypass-first groups were: major amputation rates 30 days post-procedure, 5.9%, and 3.9%; mortality rates 30 days post-procedure, 3.9%, and 0%; oneyear AFS rates, 71.7%, and 79.5%; OS rates, 73.5% and 83.9%; and limb salvage rates, 88.8%, and 91.0%. Multivariate-analysis of all subjects in the two groups revealed that the OS rates were affected by four risk factors as follows: (1) age greater than 80 years, (2) CAD, (3) CHF, and (4) a non-ambulatory limb. Conclusion: For patients with CLI due to BTK lesions and whose saphenous veins are in poor condition or are in poor general condition having two or more of the four severe risk factors, the EVT-First p...

Increase in skin perfusion pressure predicts amputation-free survival after lower extremity bypass surgery for critical limb ischemia

“…2 We have deduced that restoring the SPP to 40 mmHg would significantly heal the wound and produce a better prognosis. Although some studies have set a certain SPP as an immediate indicator of successful revascularization, [23][24][25][26][27] only a few have examined the actual prognosis according to the postoperative SPP. 9,10 SPP has been known to measure ischemia in the presence of calcified arteries in CLI patients in which ABI may show an abnormally high value.…”

Barthel Index and Outcome of Open Bypass for Critical Limb Ischemia

“…Factors other than BI and gender were indicated to be significant in previous reports. [2][3][4][5][6] Post-BI <60, ESRD, and hypoalbuminemia were identified as significant predictors of both OS and AFS on multivariate analysis ( Table 3). can be measured after successful revascularization followed by adequate wound management and rehabilitation.…”

Comparison of perfusion values after percutaneous transluminal angioplasty according to the severity of ischaemia in the diabetic foot

“…This result might reflect a paradigm shift towards the PTA in revascularisation for severely ischaemic feet. In the past, the gold standard for the treatment of severely ischaemic limbs has been open bypass surgery as the therapeutic results of PTA appeared to be less effective. In this study, we demonstrated that PTA can be performed without any particular contraindications even in patients with severe ischaemia with a high surgical risk.…”