O-142 - COMPARISON OF CLINICAL OUTCOMES, INCLUDING THE WOUND HEALING RATE, BETWEEN INFRAMALLEOLAR BYPASS TO THE PEDAL ARTERY AND THAT TO THE PEDAL BRANCH ARTERY IN THE MODERN ENDOVASCULAR ERA.

TOPIC:
Peripheral Occlusive Arterial Disease
AUTHORS:
Kodama A. (Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine ~ Nagoya ~ Japan) , Kobayashi T. (Department of Cardiovascular Surgery, JA Hiroshima General Hospital ~ Hiroshima ~ Japan) , Guntani A. (Department of Vascular Surgery, Saiseikai Yahata General Hospital ~ Kitakyushu ~ Japan) , Koyama A. (Department of Vascular Surgery, Ichinomiya Municipal Hospital ~ Ichinomiya ~ Japan) , Yamada T. (Haruoka-dori Clinic ~ Nagoya ~ Japan) , Mii S. (Department of Vascular Surgery, Saiseikai Yahata General Hospital ~ Kitakyushu ~ Japan) , Ishibashi H. (Division of Vascular Surgery, Department of Surgery, Aichi Medical University ~ Nagakute ~ Japan) , Matsushita M. (Department of Vascular Surgery, Ichinomiya Municipal Hospital ~ Ichinomiya ~ Japan) , Banno H. (Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine ~ Nagoya ~ Japan) , Komori K. (Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University School of Medicine ~ Nagoya ~ Japan)
Introduction:
Inframalleolar (IM) bypass has been reported to demonstrate acceptable patency and limb salvage in chronic limb-threatening ischaemia (CLTI) patients. When pedal artery (PA; dorsalis pedis artery or common plantar artery) are occluded with patent pedal branch artery (PBA; medial tarsal, lateral tarsal, medial plantar, or lateral plantar artery), the PBA could be selected as recipient vessels. According to the global vascular guideline (GVG), absence of a suitable PA target (e.g., GLASS IM P2) may be considered no-option disease patterns in patients with advanced CLTI. There have been some published reports regarding clinical outcomes in patients who underwent PBA bypass. However, many of them were small, single-centre studies and were conducted two decades ago or more when endovascular treatment (EVT) was less developed. Furthermore, little information is available regarding the wound healing rate in patients following inframalleolar bypass and the differences between PA bypass and PBA bypass. Therefore, the aim of this study was to evaluate recent long-term clinical outcomes, including wound healing, in patients following PBA bypass and to compare results between IM bypass to the PA and that to the PBA.
Methods:
We reviewed prospectively collected data from 208 consecutive patients after IM bypass performed over a period of six years at five hospitals. Patients were divided into two groups based on the distal anastomotic artery: the PA group and the PBA group. The primary outcome was wound healing, and secondary outcomes included loss of patency and limb and life prognosis. Complete wound healing was defined as complete epithelialization of all wounds on the affected limbs without death or major amputation. The duration from the initial bypass surgery to complete epithelialization for the first time was defined as the wound healing time. In patients who underwent major amputation, the healing time was considered infinite.
Results:
In this study, 208 CLTI patients were enrolled. The mean age was 72 years, and the prevalence of diabetes mellitus, and hemodialysis-dependent renal failure was 78% and 56%, respectively. WIfI clinical stages 4 accounted for 70%. Of these patients,174 (74%) had PA bypass, whereas 34 (16%) had PBA bypass. Patients in the PBA group were significantly younger than those in the PA group (69 ± 7 vs. 73 ± 9, P = .03). Although early (30-day) graft failure was more common in the PBA group, late clinical outcomes, including the wound healing rate (79% at 1-year in the PA group and 84% in the PBA group, P=.74), were similar between the two groups. The overall estimated median wound healing time was 104 [IQR, 52-247] days (109 [IQR, 52-247] days in the PA group and 97 [IQR, 55-278] days in the PBA group, P=.75). The primary patency in the PA group and the PBA group was 46% and 34% at 3 years, respectively (P=.09). Moreover, there were no significant differences in the other clinical outcomes, including freedom from MALEs (P=.01), limb salvage (P=.89), amputation-free survival (P=.15), and overall survival (P=.19). On multivariate analysis, the Global Limb Anatomic Staging System (GLASS) IM grade (HR, 0.73; 95% confidence interval [CI], 0.58-0.93: P=.006); wound, ischemia, and foot infection (WIfI) wound grade (HR, 0.67; 95% CI, 0.51-0.89: P<.01); and WIfI foot infection grade (HR, 0.79; 95% CI, 0.65-0.96: P=.02) were independent predictors of wound healing.
Conclusion:
The current study revealed that wound healing in patients following PBA bypass was acceptable and comparable to that following PA bypass. In the modern era, including high prevalence of infrapopliteal angioplasty, our results could provide useful information to clinicians in actual clinical settings. Moreover, PBA bypass may be an alternative revascularization procedure to avoid major amputation when the pedal artery is occluded, such as in the GVG IM P2 grade. Prospective multicenter larger studies are warranted to confirm the findings of this study and to compare PBA bypass and IM EVT in anatomical "no-option" CLTI.
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