M. Khalil2, F. J. Veith2, G. J. AlAwwa2, L. Flores2, P. Haser2, A. J. Tortolani2, N. J. Gargiulo2 2The Brookdale University Hospital and Medical Center,Surgery,New York, NY, USA
Background: Polytetrafluoroethylene (PTFE) tibial and peroneal bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia. We hypothesize superior short (30 day) and long-term (1/5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation. This reviews our 40-year experience.
Methods: A retrospective analysis was performed on a cohort of 23,391 patients with critical limb ischemia requiring revascularization between July 1977 and January 2017. In this cohort, 443 (1.89%) of the 23,391 patients underwent 443 PTFE bypasses to a tibial or peroneal artery without any adjunctive procedure. In this same cohort, 103 (0.44%) patients had no distal target vessel for revascularization despite thrombolytic and/or anticoagulation/anti-platelet therapy and required primary amputation. Cumulative life table primary and secondary patency and limb salvage rates were calculated for all PTFE tibial and peroneal artery bypass procedures. Short (30 day) and long-term (1 year/5 year) cardiovascular morbidity and mortality were compared between the PTFE and primary amputation group. In addition, ethnic background, TASC distribution, hemoglobin A1C levels, and inflammatory mediators (CRP, IL-6, and IL-10) were compared. Multivariate logistic regression was used to calculate intergroup differences with significance determined as P<0.02.
Results: Five- and 10-year primary patency and five- and 10-year limb salvage for the PTFE cohort was 34.0%, 33%, 73.3%, and 33% respectively. Short term (30 day) cardiovascular outcome in the PTFE (0.3%, 0.5%, 0%) cohort far exceeded that in the primary amputation (3%, 7%, 21%) group with regards to stroke, MI and death. These short term cardiovascular benefits were also observed long term both at 1 and 5 years in the PTFE (0.7%, 1.1%, 9%) cohort as compared to the primary amputation (5%, 13%, 17%) cohort.
Conclusions: PTFE bypasses without adjunctive procedures to infrapopliteal arteries is an acceptable alternative option for those patients without autologous vein facing imminent amputation. Several important perioperative strategies may help improve PTFE graft patency and overall limb salvage. We have observed a superior short (30 day) and long-term (1/5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation.