A Staged Revascularization Strategy for Chronic Limb-Threatening Ischemia With GLASS Stage IMP2 Disease: Distal Bypass Following Infrapopliteal/Pedal Endovascular Therapy.

Patients with chronic limb-threatening ischemia (CLTI) and Global Limb Anatomic Staging System (GLASS) stage IMP2 disease often lack suitable inframalleolar target arteries for distal bypass on conventional imaging, rendering them technically ungraftable. We adopted a staged revascularization strategy consisting of initial infrapopliteal/pedal endovascular therapy (EVT) to establish graftable pedal arteries, followed by distal bypass using autologous saphenous vein grafts before restenosis or reocclusion occurred. Two patients with Rutherford category 5 CLTI underwent this strategy after angiography and duplex ultrasonography failed to identify suitable bypass targets. Distal bypass was successfully performed several weeks and a few days after the initial EVT, respectively. Although restenosis of the graft and pedal arteries occurred during follow-up and required multiple additional EVT procedures, limb salvage was achieved in both patients until death from nonvascular causes at 6 and 12 months after bypass surgery. This staged strategy may represent a feasible treatment option for carefully selected patients with GLASS stage IMP2 CLTI who are initially considered unsuitable for distal bypass.