Pedal Bypass in CLTI: A Tale of Excellent Results But Decreasing Utilization
Recommended Citation
Chamseddine H, Shepard A, Hoballah JJ, Nypaver TJ, Weaver M, Boules TN, Kavousi Y, Onofrey K, Peshkepija A, Kabbani LS. Pedal Bypass in CLTI: A Tale of Excellent Results But Decreasing Utilization. J Vasc Surg 2024; 80(3):e63-e64.
Document Type
Conference Proceeding
Publication Date
9-1-2024
Publication Title
J Vasc Surg
Abstract
Objectives: The technical challenges of pedal bypass (PB) coupled with the increased use of endovascular modalities 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, middle, and low-volume centers. Methods: Patients receiving a PB for chronic limb-threatening ischemia (CLTI) between 2003 and 2023 were identified in the Vascular Quality Initiative (VQI). PB was defined as a bypass to an infra-malleolar vessel. Centers were categorized into tertiles based on their annual volume of PB procedures: high-volume (HVC, >4 PB/year; n = 1184 patients), middle-volume (MVC, 2-4 PB/year; n = 928 patients), and low-volume (LVC, <2 PB/year; n = 1354 patients) centers. Kaplan-Meier and Cox regression analyses were used to evaluate the long-term outcomes of patency, major amputation, reoperation, and major adverse limb events (MALE). Results: The ratio of PB to IIB dropped from 14% to 4% between 2003 and 2023 (Fig 1). The distribution of centers was as follows: 5% (16/302) HVC, 13% (38/302) MVC, and 82% (248/302) LVC. Notably, 19% of centers (56/302) did not perform any PB surgery. The average overall patency was 80% at 1 year. At 18 months follow-up, HVC achieved lower rates of amputation (17% vs 20% vs 22%; P = .045), reoperation (20% vs 23% vs 27%; P = .046), and MALE (34% vs 38% vs 42%; P = .014) compared with MVC and LVC, respectively. On multivariate Cox regression analysis, HVC were associated with a 21% decrease in the risk of loss of primary patency (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66-0.95; P = .01), 23% decrease in the risk of amputation (HR, 0.77; 95% CI, 0.61-0.98; P = .034), 25% decrease in the risk of reoperation (HR, 0.75; 95% CI, 0.60-0.95; P = .016), and 22% decrease in the risk of MALE (HR, 0.78; 95% CI, 0.66-0.93; P = .005) compared with LVC (Fig 2). On average, centers achieved a 4% reduction in MALE (HR, 0.96; 95% CI, 0.94-0.98; P = .012) for every additional PB procedure performed annually. Conclusion: PB is not frequently utilized in North America despite an excellent 80% 1-year patency rate. This declining rate raises concerns as to whether patients with CLTI are being offered every limb salvage option. These patients 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
80
Issue
3
First Page
e63
Last Page
e64
