Pedal branch artery bypass: A viable limb salvage option

Purpose: We reviewed our experience with pedal branch artery (PBA) bypass to confirm the role of these target arteries for limb salvage and to identify patient and technical factors that may be associated with graft patency and limb salvage. Methods: In. this retrospective study we analyzed 24 vein grafts to PBAs performed from 1988 to 1998 for limb salvage in 23 patients who had no suitable tibial, peroneal, or dorsal pedal target arteries. These PEA grafts were compared with 133 perimalleolar posterior tibial, defined at or below the ankle, or dorsalis pedis bypass grafts performed contemporaneously; the Kaplan-Meier life table was used in the analysis of graft patency and limb salvage. Life table analyses and logistic regression analysis of prognostic patient variables were also performed. Results: The PEA bypass represented 3% of infrainguinal revascularizations for chronic critical limb ischemia at our institution over the study period. Patients who received PEA bypasses were more likely to be male (92% vs 69%, P = .02) with lower incidences of overt coronary artery disease (33% vs 50%, P = .12) and stroke (0% vs 15%, P = .04), and a higher incidence of end-stage renal disease (21% vs 8%, P = .06) than those undergoing perimalleolar bypass. Seventeen percent of PEA bypasses were performed with the anterior lateral malleolar artery, a vessel not previously described as a common bypass target. Two-year primary patency and limb salvage for PEA versus perimalleolar bypass was 70% versus 80% (P = .16) and 78% versus 91% (P = .28), respectively. Patency and Limb salvage rates were no different in bypasses with above-knee or below-knee inflow arteries. Conclusion: An autogenous vein bypass to the PEA, though rarely required, provides acceptable primary patency and limb salvage when compared with perimalleolar tibial artery bypass when no suitable, more proximal target arteries are available. The PEA bypass should be considered before major amputation is undertaken.