Sahar Ali, Ahmed M Rashed, Ahmed Hassan, Ashraf Elnaggar, Hesham Aboloyoun
Bypass after failed PTA was independently associated with poorer AFS after multivariable adjustment for age, chronic kidney disease, frailty, WIfI stage 3-4, and conduit risk (HR, 1.88; 95% CI, 1.17-3.03; p=0.009). These groups differed substantially at baseline, and unmeasured confounding by indication and anatomical complexity cannot be excluded; the observed differences most likely reflect a higher-risk clinical phenotype rather than a causal effect of the prior endovascular attempt. Endovascular failure pattern may therefore be a useful prognostic marker when planning CLTI revascularization.
OBJECTIVE: Prior studies evaluating infrainguinal bypass after failed endovascular therapy often group all failures together. This study compared outcomes after infrainguinal bypass for chronic limb-threatening ischemia (CLTI) among patients undergoing primary bypass, bypass after failed PTA, and bypass after restenosis/reocclusion following initially successful endovascular therapy.
METHODS: This retrospective study included CLTI patients undergoing infrainguinal bypass at a tertiary university hospital between 2020 and 2025. Patients were divided into three groups: primary bypass, bypass after failed PTA, and bypass after restenosis/reocclusion. The primary outcome was amputation-free survival (AFS). Secondary outcomes included limb-based patency and major adverse limb events (MALE). Kaplan-Meier analysis and multivariable Cox regression were performed.
RESULTS: A total of 235 patients were included: 100 primary bypass, 65 bypass after failed PTA, and 70 bypass after restenosis/reocclusion. MALE was more frequent after failed PTA than after primary bypass or restenosis/reocclusion (30.8% vs 14.0% and 22.9%; p=0.03). Two-year AFS was 68.0%, 47.7%, and 58.6%, respectively. On Cox regression, bypass after failed PTA (p=0.009) and high conduit risk (p=0.022) independently predicted loss of AFS.
CONCLUSION: Bypass after failed PTA was independently associated with poorer AFS after multivariable adjustment for age, chronic kidney disease, frailty, WIfI stage 3-4, and conduit risk (HR, 1.88; 95% CI, 1.17-3.03; p=0.009). These groups differed substantially at baseline, and unmeasured confounding by indication and anatomical complexity cannot be excluded; the observed differences most likely reflect a higher-risk clinical phenotype rather than a causal effect of the prior endovascular attempt. Endovascular failure pattern may therefore be a useful prognostic marker when planning CLTI revascularization.