National Trends in Pedal Bypass Surgery: Are We Offering Every Chance to Patients with Critical Limb Ischemia?

Document Type

Conference Proceeding

Publication Date

6-1-2024

Publication Title

J Vasc Surg

Abstract

Objectives: Pedal bypass (PB) has been shown to increase limb salvage in chronic limb- threatening ischemia (CLTI). However, increased use of endovascular modalities coupled with the technical challenges of PB jeopardizes its potential as a valuable revascularization modality. This study aims to assess the temporal trends in the use of PB and to compare its outcomes between high and low-volume centers. Methods: The Vascular Quality Initiative (VQI) infrainguinal bypass (IIB) module was queried for all procedures performed between 2003 and 2020. Pedal bypass was defined as a bypass to the dorsalis pedis artery, the posterior tibial artery at the ankle, or the tarsal and plantar arteries. The annual ratio of PB to IIB was calculated and trended for 18 years. The annual rate of PB performed at each center was also calculated, and centers were stratified into high-volume (≥4 PB/year) and low-volume (≤2 PB/year) centers. Multivariate Cox regression analysis was done to evaluate the independent association of center volume with the outcomes of primary patency, re-operation, major amputation, and mortality. Results: The rate of PB surgery dropped from 14% in 2003 to 4% in 2020 (Fig 1). Only 7% (19/267) of participating centers were high volume, while 15% (40/267) of participating centers did not perform any PB surgery. Compared to all IIB patients, patients undergoing PB were more likely to be diabetic, have tissue loss, and have a previous ipsilateral infrainguinal peripheral vascular intervention (Table I). The average primary patency of PB at 1-year was 85%. High-volume centers achieved higher 1-year primary patency (88% vs 81%; P =.003) and lower 1-year re-intervention (14% vs 19%; P =.04) compared to low-volume centers. On multivariate Cox regression, patients in high-volume centers had a 40% decrease in the hazard of loss of primary patency (HR, 0.62; 95% CI, 0.48-0.81) and a 30% decrease in the persistence of ischemic symptoms (HR, 0.68; 95% CI, 0.53-0.87) compared to those in low- volume centers. Conclusions: PB is not frequently utilized, even though it has an excellent 1-year 85% patency rate. High-volume PB centers have better patency rates than low-volume centers. The rate of PB in North America is declining, a finding that raises the concern as to whether CLTI patients are being offered every limb salvage option. Patients with CLTI may benefit from evaluation at centers offering PB before being subjected to other revascularization modalities or a major limb amputation. [Formula presented] [Formula presented]

Volume

79

Issue

6

First Page

e264-e265

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