Endovascular therapy has increasingly become an initial option for the treatment of critical lower limb ischemia, but there are still indications for bypass surgery in some patients, according to Dr. Werner Lang.
Dr. Werner Lang
Despite data in favor of endovascular treatment, bypass surgery still offers the best therapy with respect to long-term patency. Even in patients for whom healing time may be short, pedal vein grafts may still be the treatment of choice, said Dr. Lang at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.
Diabetic patients in particular may benefit from the bypass surgery approach. There are no prospective randomized trials with diabetic patients that have shown, with sufficient evidence, an advantage in outcomes after endovascular therapy. However, outcomes for subgroups in some studies suggest that endovascular procedures are preferable in diabetic patients who have multifocal tibial artery stenosis or occlusions.
In addition, there are trends indicating that limb salvage rates are similar for endovascular therapy and bypass surgery. This is possible because – even though its long-term patency rates are lower – endovascular therapy is actually sufficient for many patients: Their ischemic lesions will heal within the patency period of the endovascular therapy, and thus long-term patency is not needed in all cases.
Dr. Lang, professor of surgery at the Friedrich-Alexander University Erlangen-Nuremberg (Germany) and chief of the vascular surgery department at University Hospital Erlangen, presented evidence showing that the selection of patients for either endovascular therapy or bypass surgery should depend on the ability to restore blood flow to the pedal arch with respect to the angiosomes of the ischemic lesion. Endovascular therapy must be considered inferior for any patients in whom this goal is not attainable, which can be the case for diabetic patients in particular.
"Another reason for a bypass-first strategy is the ability to combine vascular surgery with plastic reconstructive surgery – [for example,] free flaps with a microvascular anastomosis. For diabetic patients, a microvascular anastomosis will not usually be possible after endovascular therapy alone, as the quality of the vessel wall of the original artery is generally poor in diabetic patients even after such therapy," Dr. Lang said in an interview.
Finally, the decision between a bypass-first strategy and an angioplasty-first strategy should depend not only on angiographic findings alone, but also on clinical characteristics and the need to achieve direct revascularization of the pedal arteries, Dr. Lang added.