Peroneal Bypass Versus Endovascular Peroneal Intervention for Critical Limb Ischemia

SLR - March 2019 - Richard Bruno

Scientific Literature Review

Reviewed By: Richard Bruno, DPM
Residency Program: Eastern Virginia Medical School, Virginia Beach, VA

Podiatric Relevance: The risk of peripheral vascular disease increases with the number of comorbidities a patient has. Vascular surgery plays a key role in limb salvage as various intervention options are possible, with controversy over what is the best approach. The main objective of this retrospective study was to investigate the results of peroneal bypass versus endovascular peroneal intervention (EPI) for critical limb ischemia (CLI), especially in those patients with a single vessel runoff to the foot.

Methods: This level III retrospective study was performed from 2006 to 2013 in patients with a Rutherford 4-6 score for CLI. Patients underwent either peroneal bypass or EPI with lesions identified by angiography. Each group was graded with a runoff score based on pedal arch circulation as well as collateral flow to the foot. There were no restrictions to patient comorbidities. There were 200 limbs receiving bypass and 138 limbs receiving EPI. The mean follow-ups were 24 months and 14.5 months with average age of patients at 76 and 74, respectively. Patients were analyzed via complications, subsequent interventions, minor and major amputations, primary and secondary patency, mortality and wound healing. Patients received antiplatelet therapy via none, Aspirin, Clopidogrel or dual therapy.

Results: For the bypass group, the target artery was the peroneal in 92.5 percent and the tibioperoneal trunk in 7.5 percent of cases. Bypass grafts were the great saphenous vein in 70.5 percent, autologous vein in 23.5 percent and prosthetic conduit in 6 percent. Thirty-eight patients underwent a combined vascular procedure. EPI patients were noted to have more comorbidities with cardiac disease, diabetes mellitus and renal disease, but fewer smokers. The peroneal artery was treated with balloon angioplasty in all cases, atherectomy in 5.8 percent and adjunctive stenting in 6.5 percent. Ninety-four patients underwent combined femoropopliteal or iliac intervention. Wounds with ischemia were more frequent in bypass patients with lower infection rates seen. Perioperatively, 4.5 percent of bypass patients had heart attacks and more incision complications. At 12 months follow-up, bypasses had better primary patency results at 47.9 percent versus 23.4 percent, primary assisted patency (63.6 percent versus 42.2 percent) and secondary patency (74.2 percent versus 63.5 percent). Wound healing results in bypasses were 52.6 percent versus 37.7 percent for ELI at one year. No amputations occurred in 81.5 percent for bypass versus 74.7 percent for ELI. Bypass minor and major amputations were 29 and 13 versus 20 and 4 for ELI, respectively. Each intervention had similar reintervention numbers. Postoperative ABIs were higher in the bypass group with an increase seen of 40.5 percent versus 28.3 percent. Mortality rates at four years were 27.5 percent for bypass and 14.5 percent for ELI.

Conclusions: Vascular compromise is common in our patients thus making limb salvage difficult. Bypass and endovascular options for vessels are viable options, even without a major or multiple vessel runoff to the foot. Limitations were noted with selection bias for treatment options based on comorbidities and bypass targets. Also, the shorter follow-up for endovascular patients may have skewed intervention results. In conclusion, EPI may produce similar and successful outcomes as compared to bypass in high-risk patients.