AN ANALYSIS OF FEMOROPOPLITEAL BYPASS AFTER FAILED ENDOVASCULAR THERAPY: ARE WE BURNING BRIDGES?

OBJECTIVE-Surgical bypass after failed endoluminal revascularization is considered by many to be justification for an “endovascular first” approach to arterial occlusive disease. The purpose of this study is to evaluate the surgical outcome of femoropopliteal bypass after failed endovascular therapy.
METHODS-A retrospective review of patients undergoing femoropopliteal revascularization between October 2001 and July 2007 was undertaken. Cases of surgical bypass after failed endovascular treatment (secondary bypass) were selected and compared to primary bypass cases. Clinical and demographic variables potentially associated with the endpoints of patency and limb salvage were collected and analyzed with univariate and multivariate statistical methods.
RESULTS-164 primary bypass grafts were compared to 42 secondary grafts. The mean time from endovascular procedure to secondary bypass was 159±31 days (range 1-806 days). There was no significant difference in patient comorbid profiles or Rutherford category at the time of bypass. 50% of each group had one or no patent tibial vessels. Kaplan-Meyer life table analysis demonstrated six and twelve-month patency rates for primary bypass of 84% and 80%; and for secondary bypass of 77% and 62% (P = 0.008, H.R. = 2.12). Amputation rate was significantly higher in the secondary bypass group compared to primary bypass (28.6% versus 18.1%, P = 0.04).
CONCLUSIONS-Femoropopliteal bypass after failed endovascular treatment has a significantly lower patency and an inferior limb salvage rate compared to primary bypass. These data demonstrate that the concept of “surgical fallback” after endoluminal treatment is flawed, and potentially detrimental to a subset of patients.