Optimal outcome after tibial arterial bypass.

To evaluate factors for the optimal outcome after tibial arterial bypass for lower extremity ischemia, we analyzed our experience with 1,359 such bypasses during the last ten years. There were 869 males and 490 females, of whom 739 patients (54 percent) had diabetes. The average age was 68 years. One thousand and twenty-four bypasses were performed using the atraumatic valve incision in situ technique, 281 bypasses using free vein grafts and 54 bypasses with synthetic materials. These bypasses were taken to the anterior tibial (312 patients), posterior tibial (341 patients), peroneal (520 patients) and dorsalis pedis arteries (125 patients). Inflow arteries included external iliac (two patients), common (435 patients), superficial (472 patients) and profunda femoris arteries (259 patients). In certain instances, popliteal and tibial arteries were used for inflow (short bypasses). Limb salvage was the significant indication (95 percent). The overall cumulative primary patency rate at five years was 68 percent and secondary patency was 76 percent. In situ bypasses had the best secondary patency rate of 80 percent at five years followed by free vein grafts of 70 percent and synthetic bypasses of 33 percent. The choice of inflow or outflow arteries did not influence the patency rate in any category. The overall limb salvage rate was 94 percent at five years. Short bypasses using free vein grafts had a similar patency to long free vein graft but lower patency than long in situ bypasses. These data demonstrate that bypasses to tibial arteries, using autogenous vein for ischemia of the lower extremity and limb salvage, have long term durability. In situ bypass with a complete saphenous vein is the best conduit for such reconstructions. We suggest that tibial arterial bypass should be strongly considered in all instances for limb salvage when autogenous vein is available before resorting to primary amputation.