The benefits of secondary interventions in patients with failing or failedpedal bypass grafts

BACKGROUND: Autogenous bypass grafts to pedal arteries have successfully sa lvaged limbs and restored function in patients with critical ischemia. The benefits of secondary interventions to save failing or already failed graft s remains uncertain. METHODS: A retrospective analysis was made of consecutive pedal bypasses pe rformed between 1987 and 1998. Patency and limb salvage by life-table analy sis and variables affecting outcome were compared with the log-rank test. RESULTS: Two hundred thirteen patients, 144 males, 69 females (mean age 68 years, range 30 to 91) underwent pedal bypass grafting in 228 limbs using a utogenous vein grafts (nonreversed saphenous vein, n = 190; reversed, n = 1 5; composite, n = 23). One-hundred fifty-seven patients were diabetic, 34 h ad renal insufficiency (serum creatinine >2.0), and 14 were on dialysis. Ga ngrene or ulceration were present in 224 patients, rest pain in 24. Cumulat ive primary and secondary patency rates were 57% and 67% at 5 years. Limb s alvage was 78% at 5 years. Secondary interventions in 46 patients included patch angioplasty/surgical revision (n = 28), thrombectomy (n = 15), thromb olysis (n = II), and balloon angioplasty (n = 6). Patency in 19 of 26 (73%) failed grafts and in 19 of 20 (95%) failing grafts could be restored initi ally. Cumulative 2-year patency and limb salvage rates following reinterven tions were 36% and 58%, respectively. Patency rates and limb salvage for fa iled grafts (7%, 44%) were significantly worse than those for failing graft s (81%, 77%; P <0.0001, P <0.05, respectively), All patients with renal ins ufficiency who underwent reinterventions for failed or failing grafts requi red major amputation within 1 year (P <0.0001 versus those without renal in sufficiency). CONCLUSION: Autogenous pedal bypass grafts are durable operations with exce llent long-term patency and limb salvage rates. Revision of failing grafts has been effective using both endovascular and surgical techniques. Failed grafts have poor long-term patency and moderate limb salvage rates, and our data do not justify secondary procedures to attempt to save failed grafts in patients with renal insufficiency. Am J Surg. 1999;178:151-155. (C) 1999 by Excerpta Medica, Inc.