Three Time Redo Infrainguinal Bypass for Extreme Limb Salvage
Barbara Melendez1, Jeffrey Hnath2, Chin-Chin Yeh2, Benjamin Chang2, R. Clement Darling, III2.
1Albany Medical College, Albany, NY, USA, 2The Vascular Group, Albany, NY, USA.
Bypasses fail at well accepted rates; however the futility of performing a three time redo infrainguinal bypass is unclear. The purpose of this study is to evaluate the patency and limb salvage rates of three time redo bypasses. Methods:
A single institution database was searched for patients that underwent three time redo infrainguinal bypasses. Demographics, procedural details, and outcomes were compared using Chi square analysis and log rank analysis. Results:
From 2006 to 2016, 51 limbs underwent 3 time redo bypasses, 23 with venous conduit and 28 with prosthetic graft for a mean follow-up of 45 months (range 1 - 196). The vein bypass group (VBG) and prosthetic bypass group (PBG) were similar in terms of age (63, 49-79 vs. 68, 53-87, p 0.08) and sex. Comorbidities were comparable hypertension, hypercholesterolemia, COPD, diabetes, and tobacco use. The indications for procedure were similar between VBG and PBG respectively; claudication (0 vs. 1), rest pain (15 vs. 14, p 0.39), and tissue loss (8 vs. 13, p 0.56). The bypass outflow was similar in both groups (below knee popliteal: 3, 13% VBG vs. 9, 32% PBG p0.18 and tibial: 20, 87% VBG vs 19, 68% PBG p0.18). The VBG had 5 single piece leg or arm vein and 18 splice veins. The PBG group was comprised of 2 homograph and 26 PTFE bypasses. Perioperative major amputation rates were significantly lower in the VBG compared to PBG (3,13% vs 11,39%, 0.006), however long term patency and amputation free survival only trended towards favoring VBG (p 0.063 and p 0.063 respectively). Conclusions:
Three time redo infrainguinal bypasses appear to offer acceptable patency and limb salvage rates after multiple failed bypasses. Enthusiasm for prosthetic conduit, if adequate venous conduit is available, should be tempered.
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