IYSC09 - The role of completion angiography in femoro-tibial bypass

Objectives: Femoro-tibial bypass for critical limb threatening ischemia(CLTI) is a technically demanding intervention. Despite the standardization of several details of this intervention, the role of completion angiography is still a matter of debate. The present study aims to evaluate the role of completion angiography(CA) in femoro-tibial bypass and its impact on patency.

Methods: All consecutive patients treated with femoro-tibial bypass 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 artery (common or superficial), with distal anastomosis in tibial (posterior/anterior/peroneal) or pedal arteries. The bypasses were generally performed with ex-situ devalvulated great saphenous vein(GSV), and a completion angiography was routinely performed. Primary endpoints were to determine the rate of defect detected by CA and the adjunctive procedures performed to correct them. Secondary endpoint was to assess the bypass primary patency during the follow-up, performed by duplex scan at 6 months and yearly thereafter.

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% on dialysis. A composite autologous vein bypass was performed in 15% of cases; the distal anastomosis was performed in 77% to the tibial and 33% to the foot arteries. At CA, 24(9%) defects were identified: 14(50%) vein defects (6-vein stenosis, 8-residual valve), 7(25%) post-anastomotic stenoses due to clamp injury, 4(16%) distal artery atherosclerotic stenoses and 3(14%) arterial spasms. All the defects were treated intraoperatively, 5(21%) by surgical revision and 19 (79%) by endovascular angioplasty. The 30-day occlusion rate was 7%(20) due to inadequate outflow, not in patients with defect treated. 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 the 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 was the use of composite vein graft and dialysis (Odd ratio(OR): 2.1, 95% confidence-interval(CI) 1.3-3.4,P=.04 and OR: 1.7 95%CI 1.2-4.8, P=.04, respectively).

Conclusions: CA in femoro-tibial bypass 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 bypass without defect.