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Distal Bypass for Critical Limb Ischemia: When Endovascular Fails


Cesar Eduardo Jimenez, MD, Chairman Vascular Surgery, Hospital Universitario Clinica San Rafael, Bogotá, Colombia

Abstract Number

Introduction: Critical limb ischemia (CLI) of the lower limbs is a very frequent and growing entity worldwide, already considered an epidemic given the increase in diabetes, unhealthy lifestyles, and increased life expectancy of the population. CLI is characterized by the presence of pain at rest and tissue necrosis, manifested by chronic ulcers that do not heal and necrosis of the foot or fingers. These patients have a very ominous prognosis, with a high probability of limb loss and death. Treatments for CLI are based on the general condition of the patient, and the experience and availability of vascular surgeon resources. The diabetic and renal patients who usually present with CLI characteristically have severe infrapopliteal disease and to save the limb, require at least one of the three popliteal vessels below the foot to be able to maintain the viability of the limb and close wounds. Distal or ultra-distal bypass were the first treatments for this entity, with good salvage and permeability indexes, but they have been stopped to the extent that endovascular techniques have been positioned as the first line of treatment in patients with CLI. A 20%-30% infrapopliteal percutaneous angioplasty fails for different reasons; major arterial surgery should continue to be considered an option in the management of patients with CLI. It is a complex and technically demanding procedure for a vascular surgeon, but well performed, is an excellent choice for limb salvage. We present our experience in distal and ultra-distal bypass in patients who were taken to percutaneous angioplasty as the first option for limb salvage but failed. 

Objectives: The main objective of our work is to present our experience in limb salvage with distal surgical procedures and to determine the degree of limb salvage with these techniques. Secondary endpoints were morbidity and mortality associated with distal bypass. 

Methods: We performed a retrospective analysis of patients undergoing popliteal bypass for limb salvage for 2 years (January 2015 to January 2017) at a referral hospital in the city of Bogotá, Colombia for vascular pathologies. Inclusion criteria were patients with critical ischemia secondary to occlusive arterial disease of the popliteal, infrapopliteal, or both, who were taken to percutaneous angioplasty, but were not successful. The variables were age, sex, and type of bypass performed (popliteal-pedis, popliteal to posterior tibial, popliteal to anterior tibialis). The risk factors studied were diabetes mellitus, coronary artery disease, hypertension, chronic obstructive pulmonary disease (COPD), and renal insufficiency on dialysis. Complications related to bypass were analyzed (myocardial infarction, pulmonary embolism, stroke, wound infection, early graft occlusion, bleeding requiring postoperative transfusion, and renal failure), the type of graft used, minor amputations performed at the time of the bridge, amputation at 90 days and 30-day mortality from the procedure. Follow-up was clinically and with duplex at the third postoperative month. In addition, it was evaluated which patients had percutaneous angioplasty associated with the bypass, as an additional measure to optimize flow before the revascularization. Variables data were collected in an Excel database and analyzed retrospectively.

Results: We evaluated 18 patients with critical ischemia who underwent attempted percutaneous salvage angioplasty but failed. Average age was 70 years (range, 52-85 years), with 44% (n = 8) women and 55% (n = 10) men. The associated comorbidities were renal failure on dialysis 11% (n = 2), COPD 50% (n = 9), diabetes mellitus 77% (n=14), hypertension 83% (n = 15), and coronary heart disease 77% (n = 14). Bypasses performed were popliteal to posterior tibial 16% (n = 3), popliteal to anterior tibial 16% (n = 3), popliteal peroneal 30% (n = 6), and femorotibial 5.6% (n = 1). Percutaneous angioplasty associated with vascular reconstruction was performed in a segment proximal to the occlusive lesion in 38% of cases (n = 7). Vascular reconstruction with autologous vein was performed in 83% of cases (n = 15) and polytetrafluoroethylene with vein patch in 16% (n = 3); within this group, minor amputations were performed at the same time of the bypass in 61% of cases (n = 11). Digital amputation was performed in 50% of cases (n = 9) and 11% (n = 2) were transmetatarsal amputations. Within the complications, there was no early occlusion of the graft requiring surgical or endovascular revision, acute myocardial infarction was present in 5.6% of cases (n = 1), no patient had pulmonary embolism or stroke, 16% (n = 3) experienced intraoperative bleeding that required postoperative transfusion of blood, and 5.6 (n = 1) had postoperative renal failure. Major amputation was required at 90 days in 16.7% (n = 3) and 30-day mortality occurred in 5.6% (n = 1). The permeability of the 3-month graft was 83%. 

Conclusions: Open arterial surgery is still a very useful tool in limb salvage, failed angioplasty can occur, and vascular services should have other options to save the limb. Centers that claim to offer limb salvage must have surgeons with surgical and endovascular skills. Distal bypass offers a high limb salvage and low morbidity and mortality in our study.

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