The Role of Completion Angiography for Bypass to Tibial and Pedal Arteries

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INTRODUCTION: Femorotibial or pedal bypass (FTPB) for chronic limb threating ischemia (CLTI) is a technically demanding intervention. Despite the standardization of several technical and procedural details, the role of completion angiography (CA) is still a matter of debate. The present study aims to evaluate the role of CA in FTPB. METHODS: All consecutive patients treated with FTPB were prospectively collected from 2016 to 2024 into a dedicated database evaluating clinical, anatomical, surgical characteristics and medical therapies. Patients considered for the study were treated for CLTI with vein bypasses from the femoral arteries, with distal anastomosis in tibial (posterior/anterior/peroneal) or pedal arteries. The bypasses considered were performed with ex situ devalvulated great saphenous vein or composite autologous veins and a CA was routinely performed. Primary endpoint was to determine the rate of defects detected by the CA, while secondary outcomes were adjunctive procedures performed to correct them, bypass patency during the follow-up, identification of possible risk factors associated, and limb salvage. Follow-up was performed by duplex scan at 6 months and yearly thereafter. Patency rates and survival free from major events were calculated using Kaplan-Meier analysis and compared with the log-rank test. RESULTS: In the study period, a total of 256 bypasses in 238 patients were considered. Patients mean age was 74 ± 8 years and 78% were male, 62% diabetics and 13% in hemodialysis. A composite autologous vein bypass was performed in 18% (46) of cases; the distal anastomosis was performed in 67% to the tibial and 33% to the pedal arteries. At CA, 24 (9%) defects were identified: 14 (50%) vein defects (9-vein stenosis, 4-residual valve), 10 (42%) postanastomotic stenoses due to clamp injury, and 4 (16%) distal arterial lesions. All the defects were treated intraoperatively, 5 (21%) by surgical revision and 19 (79%) by endovascular angioplasty. The 30-day occlusion rate was 7%, which was attributed to poor outflow, and no occlusions occurred in patients who received defect treatment. The 30-day rates of major amputation and mortality were 4% and 8%, respectively. The mean follow-up was 42 ± 32 months and the 5-year PP of the entire study group was 54 ± 4%. No difference was detected in primary patency between bypass with defect identification and correction and all the other patients: 57 ± 8% vs. 54 ± 5%, P = 0.67, respectively. Risk factors for the defect identification at CA were the use of composite vein graft and hemodialysis (Odds ratio [OR]: 2.1, 95% confidence interval (CI) 1.3-3.4, P = 0.04 and OR: 1.7 95%CI 1.2-4.8, P = 0.04, respectively). CONCLUSION: CA in FTPB can identify a significant number of defects, most of whom treatable by an endovascular approach. Their presence is associated with composite vein bypass and dialysis, and their identification and treatment allow to obtain a primary patency similar to that of a bypass without defect.

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