PEDAL BYPASS VERSUS TIBIAL BYPASS WITH AUTOGENOUS VEIN - A COMPARISONOF OUTCOME AND HEMODYNAMIC-RESULTS

Purpose: Autogenous vein grafts to infrapopliteal arteries performed f or chronic limb-threatening ischemia between 1984 and 1991 were review ed to determine whether bypasses to pedal arteries produce results com parable to those obtained after supramalleolar tibial or peroneal bypa sses. Methods: Pedal bypass (dorsal pedal, n = 41; below-ankle posteri or tibial, n = 12) was performed only if a suitable tibial target arte ry was not available. These grafts were compared with tibial (includin g peroneal) bypass grafts (n = 203). All grafts were placed for rest p ain (23%) or established tissue loss (77%). Results: Patients requirin g pedal bypass were more likely to have diabetes and congestive heart failure but less likely to have a history of smoking. Age, gender, pre vious myocardial infarction, and other comorbidities were similar in t he two groups. Operative mortality rates (30 days) were higher for ped al than tibial bypasses (9% vs 2%; p = 0.021), possibly reflecting the higher prevalence of diabetes, congestive heart failure, and more adv anced systemic atherosclerosis associated with severe tibial artery di sease. Most grafts were in situ saphenous vein (70% pedal vs 79% tibia l). Life-table 3-year primary graft patency (58% pedal vs 61% tibial), secondary patency (82% pedal vs 79% tibial), limb salvage (92% pedal vs 87% tibial), and patient survival (61% pedal vs 64% tibial) were co mparable in the two groups. Improved assisted primary patency and seco ndary patency rates in both groups were primarily a result of revision of graft-threatening lesions detected with noninvasive graft surveill ance before thrombosis. Mean postoperative ankle/brachial index was si milar for pedal and tibial bypasses, whereas mean duplex-estimated gra ft flow was less for pedal grafts (88 +/- 10 ml/min vs 129 +/- 6 ml/mi n; p = 0.002). Pedal bypass represented 21% of our experience with inf rapopliteal vein grafts for chronic limb-threatening ischemia and was required more frequently in diabetic patients. Operative mortality rat es were higher in patients undergoing pedal bypass, suggesting that ag gressive preoperative diagnostic studies and perioperative monitoring may be appropriate for this group. Long-term survival was similar. Con clusion: We conclude that autogenous vein pedal bypass grafts provide hemodynamic results and limb salvage rates comparable to more proximal tibial bypasses in properly selected patients.