Abstract：
BACKGROUND: The frequency of distal lower extremity bypass (LEB) for infrapopliteal critical limb threatening ischemia (IP-CLTI) has significantly decreased. Our goal was to analyze the contemporary outcomes and factors associated with failure of LEB to para-malleolar and pedal targets.
METHODS: We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized.
RESULTS: We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years.
CONCLUSIONS: Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.
METHODS: We queried the Vascular Quality Initiative infrainguinal database from 2003 to 2021 to identify LEB to para-malleolar or pedal/plantar targets. Primary outcomes were graft patency, major adverse limb events [vascular reintervention, above ankle amputation] (MALE), and amputation-free survival at 2 years. Standard statistical methods were utilized.
RESULTS: We identified 2331 LEB procedures (1,265 anterior tibial at ankle/dorsalis pedis, 783 posterior tibial at ankle, 283 tarsal/plantar). The prevalence of LEB bypasses to distal targets has significantly decreased from 13.37% of all LEB procedures in 2003-3.51% in 2021 (P < 0.001). The majority of cases presented with tissue loss (81.25. Common postoperative complications included major adverse cardiac events (8.9%) and surgical site infections (3.6%). Major amputations occurred in 16.8% of patients at 1 year. Postoperative mortality at 1 year was 10%. On unadjusted Kaplan-Meier survival analysis at 2 years, primary patency was 50.56% ± 3.6%, MALE was 63.49% ± 3.27%, and amputation-free survival was 71.71% ± 0.98%. In adjusted analyses [adjusted for comorbidities, indication, conduit type, urgency, prior vascular interventions, graft inflow vessel (femoral/popliteal), concomitant inflow procedures, surgeon and center volume] conduits other than great saphenous vein (P < 0.001) were associated with loss of primary patency and increased MALE. High center volume (>5 procedures/year) was associated with improved primary patency (P = 0.015), and lower MALE (P = 0.021) at 2 years.
CONCLUSIONS: Despite decreased utilization, open surgical bypass to distal targets at the ankle remains a viable option for treatment of IP-CLTI with acceptable patency and amputation-free survival rates at 2 years. Bypasses to distal targets should be performed at high volume centers to optimize graft patency and limb salvage and minimize reinterventions.
摘要：
目的：下肢远端旁路术（LEB）用于the下危重肢体威胁缺血（IP-CLTI）的频率显着降低。我们的目标是分析与LEB未能达到对踝和踏板目标相关的当代结果和因素。
方法：我们查询了2003-2021年的VQI腹股沟下数据库，以识别LEB对踝旁或踏板/足底目标。主要结果是移植物通畅，主要不良肢体事件[血管再介入，脚踝以上截肢]（男性），和2年无截肢生存率。使用标准统计方法。
结果：我们确定了2331LEB手术（踝关节/足背胫骨前1265，783踝关节胫骨后端,283髌骨/足底）。LEB旁路到远端目标的患病率已从2003年的所有LEB程序的13.37％显着下降到2021年的3.51％（p<0.001）。大多数病例表现为组织丢失（81.25。常见的术后并发症包括主要不良心脏事件（8.9％）和手术部位感染（3.6％）。16.8%的患者在1年时发生严重截肢。术后1年死亡率为10%。在2年未调整的Kaplan-Meier生存分析中，原发性通畅率为50.56%±3.6%，男性为63.49%±3.27%，无截肢生存率为71.71%±0.98%。在调整后的分析中[针对合并症进行了调整，指示,导管类型,紧迫性,先前的血管干预，移植物流入血管（股/pop），伴随的流入程序，除GSV(p<0.001)外,外科医生和中心容积]导管与原发性通畅性丧失和男性增加相关.高中心体积（>5次手术/年）与改善原发性通畅性相关（p=0.015），2岁时男性较低（p=0.021）。
结论：尽管利用率下降，开放手术旁路至踝关节远端目标仍然是IP-CLTI治疗的可行选择,在2年时具有可接受的通畅性和无截肢生存率.应在高容量中心绕过远端目标，以优化移植物的通畅性和肢体抢救，并最大程度地减少再干预。
方法：我们查询了2003-2021年的VQI腹股沟下数据库，以识别LEB对踝旁或踏板/足底目标。主要结果是移植物通畅，主要不良肢体事件[血管再介入，脚踝以上截肢]（男性），和2年无截肢生存率。使用标准统计方法。
结果：我们确定了2331LEB手术（踝关节/足背胫骨前1265，783踝关节胫骨后端,283髌骨/足底）。LEB旁路到远端目标的患病率已从2003年的所有LEB程序的13.37％显着下降到2021年的3.51％（p<0.001）。大多数病例表现为组织丢失（81.25。常见的术后并发症包括主要不良心脏事件（8.9％）和手术部位感染（3.6％）。16.8%的患者在1年时发生严重截肢。术后1年死亡率为10%。在2年未调整的Kaplan-Meier生存分析中，原发性通畅率为50.56%±3.6%，男性为63.49%±3.27%，无截肢生存率为71.71%±0.98%。在调整后的分析中[针对合并症进行了调整，指示,导管类型,紧迫性,先前的血管干预，移植物流入血管（股/pop），伴随的流入程序，除GSV(p<0.001)外,外科医生和中心容积]导管与原发性通畅性丧失和男性增加相关.高中心体积（>5次手术/年）与改善原发性通畅性相关（p=0.015），2岁时男性较低（p=0.021）。
结论：尽管利用率下降，开放手术旁路至踝关节远端目标仍然是IP-CLTI治疗的可行选择,在2年时具有可接受的通畅性和无截肢生存率.应在高容量中心绕过远端目标，以优化移植物的通畅性和肢体抢救，并最大程度地减少再干预。
