SLR - January 2021 - Mallory A. Kirkland

Pedal Bypass Surgery Prevents Amputation in Patients with Critical Lower Limb Ischemia – A Single Center Experience of 99 Pedal Bypass Operations

Reference: Jorgensen MMT, Jepsen JM, Rai A, Hallenbert C, Houlind KC. Pedal Bypass Surgery Prevents Amputation in Patients with Critical Lower Limb Ischemia - A Single Center Experience of 99 Pedal Bypass Operations. Clin Surg. 2020; 5: 2915.

Level of Evidence: Retrospective Level IV

Scientific Literature Review

Reviewed By: Mallory A. Kirkland, DPM
Residency Program: St. Vincent Indianapolis – Indianapolis, IN

Podiatric Relevance: Patients with critical limb ischemia face a high risk of major amputation; hence, increasing their morbidity and mortality. In podiatry, we see infra-popliteal bypass as a reliable and effective treatment of these patients. This article sought to investigate whether bypass surgery to an artery below the ankle can prevent major amputation in patients with critical limb ischemia.

Methods: Ninety-three patients (26W:67M) underwent 99 pedal bypasses at a single vascular center in Denmark were identified using operation codes for surgery to a pedal artery registered in the national vascular registry, Karbase. This database and medical records provided information on patient characteristics, comorbidities, operation-specific information, as well as patency of reconstruction. Bypass was considered patent if there was palpable pulse distally, if the patient had sufficient ABIs and/ or if the bypass was deemed to be functioning after examination by Doppler or duplex ultrasound. Baseline was set as date of surgery and patients were followed until amputation, death, or end of study. All analyses, except for mortality analyses, were carried out at bypass level. Median amputation-free and overall survival, as well as intervention-free and overall patency, was calculated using Kaplan Meier survival analysis. Kaplan Meier survival curves were used to give an overview of the results and Cox regression analysis investigated possible significant co-variables. 

Results: Mean age was 72.3 years, with a generally higher age among females than men (77.4 vs. 70.2 years). All patients had critical limb ischemia (rest pain, non-healing ulcers, or gangrene). At the end of the study, 21/93 (23 percent) patients were alive, 70/93 (75 percent) had passed, and 2 had unknown status as they failed to follow up. Rates for primary patency, secondary patency, limb salvation, amputation-free survival, and overall survival were analyzed at 1, 5 and 10 years. Mean primary and secondary patency were both ~2.6 years. Twenty-six experienced a major amputation. Mean amputation free survival was 2.9 years. Mean overall survival was 3.8 years. Secondary findings in this article showed diabetics had a better survival rate than non-diabetics. Furthermore, former smokers did better than never smokers, which could be attributed to a more aggressive genetic predisposition.

Conclusions: The authors of this article feel that although pedal bypass is still a controversial treatment, it could potentially prevent major amputation. As a foot and ankle surgeon, we obviously wish to prevent any major amputation; however, although this technique provides another surgical option, it is extremely important to consider its low success rate, patient’s quality of life, and access to surgeons willing to perform such a surgery.

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