SS22 - Bypass Despite Patent Endovascular Treated Arterial Segments In Patients with Tissue Loss

Objectives: Limb loss despite patent bypass is a well-reported entity. Our group previously reported amputation despite patent endovascular treated arterial segment (PETAS) is the most common means of limb loss in patients undergoing endovascular intervention (EVI) for CLTI. We have performed tibial/pedal bypasses in patients who are clinically failing despite PETAS to prevent limb loss. The goal of our study was to define this subgroup and analyze the outcomes.

Methods: All patients who underwent initial infrainguinal EVI for CLTI (Rutherford 5-6) between 7/2007-12/2022 were screened. Patients who underwent tibial/pedal bypass despite PETAS for limb salvage were reviewed.

Results: EVI was performed in 551 patients (665 limbs, age 73.2±9.8(48-98), ulcer 77.9%, gangrene 22.1%, mean follow-up of 33.7 months (0-177)) 5-year limb salvage was 82±2%, survival was 26±2%. Eighty-nine patients had supramalleolar amputation, 78 (87.6%) despite PETAS or patent bypass graft. Of the 58 (8.7% of all limbs) patients who had bypass during follow-up (1 had two, two had 3 bypasses), 19 patients (20 limbs, 34.5% of bypasses) had bypass despite PETAS (12 DP, 3 distal AT, 5 PT; 17 with GSV, 2 cryopreserved veins, one composite PTFE/GSV) 2.1±1.4 months (0.5-5.0) after EVI. Seven had ev reinterventions before bypass. Morbidities included DM (90%), CKD/ESRD (45%/30%). ABI was noncompressible/falsely elevated in 80%. The EVI (75% infrapopliteal) resulted in direct/indirect angiosome-specific revascularization each in half of the patients. Multiple vessels were treated in 30%; GLASS inframalleolar descriptors were P0 in 30% and P1 in 70%. The target arterial path (TAP) was the same as the EVI in 10 and different in the remaining 10 limbs. Mean follow-up was 48±45 months (2-165) after bypass. Eleven patients died during follow-up and 5 (25%) had amputation at 3, 32, 38, 86 and 132 months; 3 with patent bypass (36, 38, 83 months) and 2 due to graft occlusion (1 and 32 months). Five required additional ev reinterventions.

Conclusions: Bypass despite PETAS can improve pedal perfusion due to either the increased flow lumen of bypass when compared to an endovascularly treated segment or by providing angiosome-specific revascularization in those with indirect revascularization after EVI, and can therefore achieve limb salvage in patients who are likely to lose their limbs despite PETAS. Tibial/pedal bypass should be considered when patients clinically regress despite angiographically patent ev-treated arteries.