Prior Endovascular Intervention Is Not Detrimental to Pedal Bypasses for Ischemic Wounds

Published:February 23, 2018DOI:


      Endovascular strategies are often preferred for revascularization of ischemic foot wounds secondary to infrapopliteal disease because of the less invasive technique and faster recovery. Bypass is typically reserved for failures or lesions not amenable to balloon angioplasty. However, the effects of an endovascular-first approach on subsequent bypass grafts are largely unknown. This study evaluates the effects of prior endovascular tibial interventions (PTIs) on successive bypasses to pedal targets.


      Patients who presented with ischemic tissue loss and tibial arterial occlusive disease to University of Pittsburgh Medical Center between 2006 and 2013 and underwent a surgical bypass to pedal arteries were included in this study. A retrospective chart review was conducted to obtain patient demographics, past medical history, extent of disease, prior tibial endovascular interventions, the treatment intervention, subsequent interventions, wound healing status, limb salvage, and patient survival. The primary outcome was primary patency of the pedal bypass graft.


      From 122 eligible patients, 27 had a PTI, whereas 95 had no prior endovascular tibial intervention (nPTI) in the treatment of ischemic pedal wounds with mean follow-up of 24.5 and 20.5 months, respectively (P = 0.36). The 2 groups were largely similar in terms of demographics, comorbidities, wound size, and degree of ischemia. Runoff scores between the 2 groups were also comparable (5.0 ± 1.6 for PTI and 4.8 ± 1.9 for nPTI, P = 0.59). The plantar artery was a more common target vessel in the PTI group, whereas the posterior tibial artery was targeted more often in the nPTI group (P = 0.04). At 12 months, those with a PTI exhibited a shorter primary patency (34.8% vs. 60.2%, P = 0.04). In a multivariate model, PTI was a significant risk factor for primary patency loss (hazard ratio 2.51, P = 0.004). Primary assisted patency and secondary patency were similar between the 2 groups. Wound healing was improved in those patients who had a prior endovascular intervention with 63.8% healed at 1 year compared with only 34.8% of those without intervention (P = 0.01). Amputation-free survival was similar (P = 0.68), as was survival alone (P = 0.50).


      Despite a decrease in primary patency, pedal bypass was not otherwise negatively affected by a PTI. Similar primary assisted patency, secondary patency, wound healing, and survival between the 2 patient populations indicate that an endovascular-first approach is a feasible treatment strategy to achieve similar clinical outcomes in the management of ischemic foot wounds.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Abu Dabrh A.M.
        • Steffen M.W.
        • Undavalli C.
        • et al.
        The natural history of untreated severe or critical limb ischemia.
        J Vasc Surg. 2015; 62: 1642-1651.e3
        • Armstrong E.J.
        • Bishu K.
        • Waldo S.W.
        Endovascular treatment of infrapopliteal peripheral artery disease.
        Curr Cardiol Rep. 2016; 18: 34
        • Chen Q.
        • Shi Y.
        • Wang Y.
        • et al.
        Patterns of disease distribution of lower extremity peripheral arterial disease.
        Angiology. 2015; 66: 211-218
        • Huang Z.S.
        • Schneider D.B.
        Endovascular intervention for tibial artery occlusive disease in patients with critical limb ischemia.
        Semin Vasc Surg. 2014; 27: 38-58
        • Fu X.
        • Zhang Z.
        • Liang K.
        • et al.
        Angioplasty versus bypass surgery in patients with critical limb ischemia-a meta-analysis.
        Int J Clin Exp Med. 2015; 8: 10595-10602
        • Soderstrom M.I.
        • Arvela E.M.
        • Korhonen M.
        • et al.
        Infrapopliteal percutaneous transluminal angioplasty versus bypass surgery as first-line strategies in critical leg ischemia: a propensity score analysis.
        Ann Surg. 2010; 252: 765-773
        • European Stroke O.
        • Tendera M.
        • Aboyans V.
        • et al.
        ESC Guidelines on the diagnosis and treatment of peripheral artery diseases: document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries: the Task Force on the Diagnosis and Treatment of Peripheral Artery Diseases of the European Society of Cardiology (ESC).
        Eur Heart J. 2011; 32: 2851-2906
        • Conte M.S.
        Critical appraisal of surgical revascularization for critical limb ischemia.
        J Vasc Surg. 2013; 57: 8S-13S
        • Mills Sr., J.L.
        • Conte M.S.
        • Armstrong D.G.
        • et al.
        The Society for vascular surgery lower extremity Threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI).
        J Vasc Surg. 2014; 59 (234.e1–2): 220
        • Rutherford R.B.
        • Baker J.D.
        • Ernst C.
        • et al.
        Recommended standards for reports dealing with lower extremity ischemia: revised version.
        J Vasc Surg. 1997; 26: 517-538
        • Conte M.S.
        • Geraghty P.J.
        • Bradbury A.W.
        • et al.
        Suggested objective performance goals and clinical trial design for evaluating catheter-based treatment of critical limb ischemia.
        J Vasc Surg. 2009; 50 (1473.e1–3): 1462
        • Gifford S.M.
        • Fleming M.D.
        • Mendes B.C.
        • et al.
        Impact of femoropopliteal endovascular interventions on subsequent open bypass.
        J Vasc Surg. 2016; 64: 623-628
        • Stadelmann W.K.
        • Digenis A.G.
        • Tobin G.R.
        Impediments to wound healing.
        Am J Surg. 1998; 176: 39S-47S