Mid-Term Results of Popliteal-Pedal Inframalleolar Vein Bypasses in Chronic Limb-Threatening Ischemia Patients After Previous Failed Tibial Endovascular Recanalization

Background: Inframalleolar bypass still preserves its role in the modern endovascular era. Aim of this study was to evaluate the mid-term outcomes of “short” inframalleolar vein bypasses in patients with chronic limb-threatening ischemia (CLTI) after the previously failed tibial endovascular recanalization. Methods: Between January 2015 and December 2021,107 CLTI patients in 3 Italian Departments of Vascular Surgery underwent “short” inframalleolar vein bypass after failed tibial endovascular recanalization. Early (30-day) and 3-year outcomes were evaluated in terms of survival, primary patency, primary assisted patency, secondary patency, and amputation-free survival. Univariate analysis of the perioperative factors affecting outcomes were performed by the means of log-rank test. The associations of procedure variables were sought based on a multivariate Cox regression analysis. Results: Distal anastomosis (inframalleolar) was mostly performed on dorsal pedis (64, 59.8%). At 30 days, bypass occlusion was recorded in 5 cases (4.6%). The mean follow-up period was 20.5 ± 17.9 months. The estimated 3-year overall survival was 66.7%. Three-year estimates of primary patency, primary assisted patency, secondary patency, and amputation-free survival were 68.5%, 70.1%, 70.2%, and 76.7%, respectively. Multivariate analysis showed a negative association of insulin treatment with primary patency (HR 4.3, P = 0.04), primary assisted patency (HR 5.1, P = 0.02), and secondary patency (HR 5.1, P = 0.02). The negative association of long-term corticosteroid use was also found with primary patency (HR 7.8, P = 0.005), primary assisted patency (HR 8.7, P = 0.003), secondary patency (HR 8.7, P = 0.003), and amputation-free survival (HR 3.9, P = 0.05). Conclusions: Short” vein bypasses to the foot arteries in CLTI patients yielded good mid-term overall patency and limb salvage rates after a failed tibial endovascular recanalization. Insulin-dependent diabetes mellitus and long-term corticosteroid use seemed to affect the outcomes.