Contemporary Outcomes following Redo Autogenous Infrainguinal Bypass

Background

Revascularization after lower extremity bypass failure poses many challenges. Despite nearly 7 decades of experience with lower extremity revascularization, there is little data on the success of redo bypass particularly when autogenous conduit is utilized. The purpose of this study is to review outcomes of redo infrainguinal bypass constructed solely of autogenous vein.

Methods

All patients who underwent redo infrainguinal bypass at a single institution by a single surgeon were retrospectively reviewed. Bypasses were categorized into 3 groups: femoral-popliteal, femoral-distal, and popliteal-distal bypasses. Since the repeat bypasses were all done for limb salvage, freedom from above or below knee amputation (FFA) was primary outcome, which was defined as the number of days from redo bypass to subsequent amputation or the most recent follow-up.

Results

From 2006 to 2016, 100 limbs underwent redo bypass. Fifty-nine (59.0%) limbs had undergone one previous bypass while 41 (41.0%) had undergone 2 or more. The redo configurations consisted of 23 (23.0%) femoral-popliteal, 70 (70.0%) femoral-distal, and 7 (7.0%) popliteal-distal bypasses. Ninety-seven (97.0%) underwent redo using autologous vein grafts including 41 (95.5%) of those who had 2 or more previous bypasses. The 3 patients who ultimately underwent prosthetic bypass had bilateral great and small saphenous veins and bilateral basilic and cephalic veins previously harvested. Nine (9.0%) limbs were subsequently amputated: 2 (2.0%) above knee and 7 (7.0%) below knee amputations. Of these, all had had 2 or more previous bypasses and 2 of the 3 patients who ultimately received prosthetic bypasses were in this group. In patients with one previous bypass, FFA was 775 days (IQR: 213–1,626 days). In patients with 2 or more previous bypasses, FFA was 263 days (IQR: 106–1,148 days). No patients with femoral-popliteal bypasses suffered amputation while 7 (10.0%) of the femoral-distal and 2 (28.6%) of the popliteal-distal bypasses suffered subsequent amputations (P = 0.067).

Conclusions

Redo infrainguinal bypass is effective in salvaging threatened lower extremities. Furthermore, once a patient is deemed a bypass candidate, revascularization with autologous vein can be achieved. A significant FFA rate is achieved with redo bypass, although patients with more distal disease are harder to salvage.

Introduction

Autogenous vein and prosthetic graft conduits are both commonly used for lower extremity revascularization in the setting of limb ischemia. Although autogenous vein has superior patency, both types of conduit thrombose and not uncommonly cannot be salvaged. Particularly in patients whose original bypass was placed for limb salvage, critical limb ischemia returns with bypass occlusion. Treatment options at this point are major amputation versus technically challenging redo infrainguinal bypass or endovascular intervention when possible.1, 2, 3, 4 Although major amputation definitively resolves the limb ischemia, it is associated with a high perioperative complication rates and negatively impacts patient quality of life.^5,6 The resulting reduced mobility limits activities of daily living, leading to progressive cognitive decline and increased postoperative mortality.³ Therefore, further attempts at revascularization are generally appropriate. Existing studies investigating outcomes following redo infrainguinal bypasses support an aggressive approach to revascularization. However, all previously published series of redo lower extremity bypasses have included a significant proportion constructed from prosthetic conduits.1, 2, 3^,7 The purpose of the current study is to review a consecutive series of redo infrainguinal arterial bypasses, focusing on contemporary postoperative outcomes and autogenous conduit utilization.