Bilateral and Redo Pedal Bypass for Critical Limb Ischemia: Is it Worth the Effort?

OBJECTIVES: While pedal bypass is accepted treatment for patients with critical limb ischemia and tibial occlusive disease, redo and bilateral pedal bypass has been reluctantly performed. The purpose of this study is to evaluate outcomes of this aggressive strategy.
METHODS: The charts of patients with bilateral or redo pedal bypass were retrospectively reviewed between 1996 and 2006. Patency, limb salvage and functional outcomes were analyzed.
RESULTS: 30 patients (60 limbs) were treated with bilateral pedal bypass, and 22 with redo pedal bypass. Mean age was 68.2±13.5. Comorbidities included diabetes (91%), ESRD (20%), CAD (61%), but smoking in only 13%. All patients were Rutherford class 4-6. The distal target was an inframalleolar tibial (43%) or pedal vessel (57%). Conduit other than greater saphenous vein was used in 26% of patients. The mean toe pressure increased from 19.5±17.3mm Hg preop to 74.2±25.8mmHg postop. Patency rates are presented in Figure 1. Freedom from major amputation was 98% and cumulative survival was 91% at 48 months. Cardiac morbidity occurred in 4%, and minor amputation was required for 62% of patients. Only 4% of patients were non-ambulatory or in an extended care facility at a mean follow up of 34.3±16.1 months.
CONCLUSIONS: Bilateral and redo pedal bypass with autogenous vein is safe and durable. Limb salvage and full functional recovery can be achieved with minimal perioperative morbidity. With increasing applications of endovascular solutions, an aggressive surgical strategy should be considered for limb salvage even in patients with significant comorbidities and a disadvantaged vein conduit.