Timing of Pedal Bypass Failure and Its Impact on the Need for Amputation

Although the utility of dorsalis pedis (DP) bypass for limb ischemia has been well established, the fate of limbs with a failed bypass to the DP artery remains unclear. Data of all patients undergoing DP bypass grafting within a 12-year period from two university hospitals' vascular registries were retrospectively reviewed. Outcomes of early (<30 days) and delayed graft failure (>30 days) were examined. The Student's t-test and chi-squared test were used for univariate analysis; patency rates and patient survival were calculated using the Kaplan-Meier product limit method. Of 1434 DP bypass grafts, 277 (19.3%) failed grafts were identified. Sixty five (4.5%) grafts failed early (within 30 days of surgery) and 212 (14.8%) failed late at a mean time of 15.3 months (range, 1.5-105 months) after initial bypass. Of the 65 limbs with early graft failure, 28 (43.1%) proceeded directly to amputation and 20 underwent additional revascularization attempts, but limb salvage was achieved in only 7 patients; in 45 (69.2%) patients no further revascularizations were attempted. Seventy-four (34.9%) patients with late graft failure underwent redo revascularization. Thirty-nine (52.6%) had their limb saved with graft revision, but 35 patients (47.3%) ultimately lost their limb. In 138 patients with late graft failure (65.1 %) no further revascularization attempts were performed. Sixty-two (44.9%) required major amputation. Overall, 49.8% of patients with failed pedal grafts ultimately suffered limb loss. Early graft failure resulted in a significantly higher rate of major amputation that did late graft failure (63.1% vs. 45.8%, respectively; p = 0.015). These results indicate that early occlusion of pedal bypass often leads to immediate major amputation and interventions to maintain graft patency in this setting are often futile. Late failure of pedal bypass is associated with a lower likelihood of amputation because of a higher rate of success of bypass revisions and a lower occurrence of critical ischemia with graft failure.