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Percutaneous Intervention for Failing Lower Extremity Bypasses is an Effective Adjunct to Improve Bypass Durability
Charles D. Fraser, III, MD1, Joshua C. Grimm, MD1, Rui Han Liu, BS1, Allen Young, BS1, Mark L. Kovler, MD1, Robert J. Beaulieu, MD1, Thomas Reifsnyder, MD2.
1The Johns Hopkins Hospital, Baltimore, MD, USA, 2The Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.

Objectives
While lower extremity bypass is an effective strategy for limb salvage in patients with severe peripheral artery disease, patency rates and freedom from amputation vary. Accordingly, we sought to investigate the efficacy of percutaneous transluminal balloon angioplasty in rescuing failing lower extremity bypasses.
Methods
All patients who underwent lower extremity bypass grafting and subsequent percutaneous intervention by a single surgeon between March 2003 May 2016 were retrospectively reviewed. Bypasses were categorized into three major cohorts femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Primary and assisted-primary patencies as well as amputation rates were calculated.
Results
During the study period, 86 patients underwent balloon angioplasty following lower extremity bypass. The median age was 67 (IQR: 59-76) and 56% were male. A preponderance had a history of diabetes mellitus (65%), hyperlipidemia (67%), heart disease (53%), chronic kidney disease (44%), and tobacco use (65%). Most were optimized on both statin (85%) and anti-platelet therapies (73%). In regards to the bypass cohorts, 35%, 41% and 24% underwent femoral-popliteal, femoral-distal, and popliteal-distal bypasses, respectively. Median primary patencies for these cohorts were 169 days (IQR: 107-930), 157 days (IQR: 106-278), and 196 days (IQR: 83-527). Similarly, median assisted-primary patencies were 1409 days (IQR: 528-1972), 1013 days (IQR: 294-1597), and 1024 days (IQR: 575-1461). Amputation rates were 7%, 9%, and 35%, respectively.
Conclusions
Maintaining a patent lower extremity bypass is critical in avoiding ongoing tissue loss and subsequent amputation. Vigilant surveillance with routine vascular lab studies can promptly identify patients at risk for graft thrombosis who might, therefore, benefit from early percutaneous intervention. As amputation rates were highest in those with more distal bypasses, vascular surgeons should exercise additional caution in this specific cohort of patients.


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