Mid-term clinical outcome of critical limb ischemia after infrapopliteal bypass surgery.

Critical limb ischemia caused by peripheral arterial occlusive disease of the infrapopliteal segment is best managed by bypass surgery with an autogenous vein conduit. Yet there remains confusing heterogeneity in the strategy, utilization, techniques, and outcomes in current practice. We reviewed our 7-year experience of infrapopliteal bypass surgery to analyze early and mid-term clinical outcomes. From May 2003 through May 2010, 63 bypasses to the infrapopliteal artery were performed in 59 patients. This comprised 32.4% of the 194 infrainguinal arterial reconstructions performed during that period. Of the 63 bypasses, 57 were performed with an autologous vein and 6 with a composite graft. For the autologous vein bypasses, a single-segment great saphenous vein (GSV) was used in 39 bypasses, which included 23 reversed, 5 in situ, and 11 non-reversed free grafts. "Spliced" vein grafts, constructed by splicing the GSV or lesser saphenous veins (LSV) together, were utilized in 18 bypasses. No deaths occurred within 30 days of surgery. Two patients (3.5%) died while hospitalized . Five grafts failed within 30 days of surgery due to thrombosis or bleeding. The primary graft patency, secondary graft patency, amputation-free survival (AFS) and overall survival were 73.7%, 82.4%, 84.7%, 88.1%, respectively at 1 year and 65.4%, 76.3%, 71.0%, 74.6% at 3 years. When patients were divided into groups based on the presence of end-stage renal disease on hemodialysis (HD), the 3-year secondary patency, AFS, and overall survival were 82.5%, 49.2, 49.2% in the HD group and 74.1%, 84.2%, 88.8% in the non-HD group. The overall survival in the HD group was significantly worse compared with the non-HD group. Infrapopliteal arterial bypass is a safe, durable and highly effective procedure in patients with CLI, with excellent mid-term patency and amputation-free survival. Renal insufficiency may be associated with a poorer limb salvage rate and long-term survival.