Blind Peroneal Artery Outflow Bypass for Limb Salvage in Patients With Severe CLTI

Chronic limb-threatening ischemia (CLTI) management involves optimizing medical therapy and revascularization tailored to patient risk factors and anatomical feasibility. Although endovascular procedures are often the first choice, bypass surgery, particularly utilizing the peroneal artery (PA) as an outflow, has demonstrated good limb salvage rates. Our study highlights the use of blind PA bypass for limb salvage in patients with CLTI with inadequate distal vessels on angiography. A retrospective chart review was carried out at University of Miami Health System from January 2012 to January 2022. Adult patients who underwent lower extremity bypass using a PA artery as an outflow vessel for CLTI were included in this study. From those, two subgroups were identified as blind PA and no-blind PA. A blind PA was defined based on Paty et al's 1998 classification as type D, E, or F. No-blind PA were defined as A, B, or C according to the same classification (Fig 1). The primary outcome assessed in this study is limb loss, with an additional analysis of patency rates. Statistical analyses encompassed descriptive analysis, as well as the application of χ2, Fisher, and analysis of variance tests for the relevant variables. A total of 25 patients with lower extremity bypass for CLTI with PA outflow were included. From those, 17 were defined as no-blind according to preoperative angiography runoff, and 8 were defined as blind PA. Sociodemographic and postoperative information is summarized in Tables 1 and 2. Blind PA bypasses had a primary patency of 25%, a primary assisted patency of 50%, a secondary patency of 75%, and a limb loss rate of 25%. Among the 17 non-blind PA bypasses, primary patency was 52%, primary assisted patency was 82.4%, secondary patency was 94.1%, and the limb loss rate was 5.9%. There were no significantly different P-values observed between both groups (Table 3). In conclusion, our study supports that blind PA outflow in open revascularization for CLTI demonstrates good limb salvage rates. Intraoperative exploration of the PA may be a viable option for aggressive limb salvage when other suitable outflow arteries are not identified on angiogram. Individual patient factors, including pre-admission condition and functional status, should guide intervention decisions. Despite study limitations due to a limited sample size, our findings provide a basis for larger studies to validate blind PA bypass as a revascularization strategy for patients with CLTI, serving as a last resort.Table ISociodemographic characterizationNo (n = 17)Yes (n = 8)Total (N = 25)P valueAge, years70.6 (9.0)67.8 (16.9)69.7 (11.8).577aGender.607b Male11.0 (64.7)6.0 (75.0)17.0 (68.0) Female6.0 (35.3)2.0 (25.0)8.0 (32.0)Ethnicity.125b Caucasian1.0 (5.9)3.0 (37.5)4.0 (16.0) Hispanic11.0 (64.7)3.0 (37.5)14.0 (56.0) African American5.0 (29.4)2.0 (25.0)7.0 (28.0)Smoking.798b Never4.0 (23.5)1.0 (12.5)5.0 (20.0) Former8.0 (47.1)4.0 (50.0)12.0 (48.0) Current5.0 (29.4)3.0 (37.5)8.0 (32.0)Hypertension15.0 (88.2)7.0 (87.5)22.0 (88.0).958bDiabetes mellitus11.0 (64.7)6.0 (75.0)17.0 (68.0).607bHyperlipidemia7.0 (41.2)3.0 (37.5)10.0 (40.0).861bCAD7.0 (41.2)2.0 (25.0)9.0 (36.0).432bPAD14.0 (82.4)6.0 (75.0)20.0 (80.0).668bCHF1.0 (5.9)1.0 (12.5)2.0 (8.0).569bCOPD3.0 (17.6)0.0 (0.0)3.0 (12.0).205bMalignancy4.0 (23.5)0.0 (0.0)4.0 (16.0).134bAtrial fibrillation2.0 (11.8)1.0 (12.5)3.0 (12.0).958bCKD2.0 (11.8)2.0 (25.0)4.0 (16.0).400bStroke0.0 (0.0)1.0 (12.5)1.0 (4.0).137bCAD, coronary artery disease; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; PAD, peripheral artery disease;Data are presented as number (%) or mean (standard deviation).aLinear model analysis of variance.bPearson χ2 test. Open table in a new tab Table IINo (n = 17)Yes (n = 8)Total (N = 25)P valueBleeding1.0 (5.9)1.0 (12.5)2.0 (8.0).569aDeep SSI0.0 (0.0)2.0 (25.0)2.0 (8.0).032aWound disruption0.0 (0.0)1.0 (12.5)1.0 (4.0).137aLength of stay, days14.8 (10.9)16.8 (9.9)15.4 (10.4).666bImprovement of symptoms.394a Mild6.0 (35.3)5.0 (62.5)11.0 (44.0) Significantly10.0 (58.8)3.0 (37.5)13.0 (52.0) No change1.0 (5.9)0.0 (0.0)1.0 (4.0)SSI, Surgical site infection.Data are presented as number (%).aPearson χ2 test.bLinear model analysis of variance. Open table in a new tab Table IIIPatency rates and limb loss rates in patients with peroneal outflow bypassNo (n = 17)Yes (n = 8)Total (N = 25)P valuePrimary9.0 (52.9)2.0 (25.0)11.0 (44.0).189aAssisted14.0 (82.4)4.0 (50.0)18.0 (72.0).093aSecondary16.0 (94.1)6.0 (75.0)22.0 (88.0).170aLimb loss rates1.0 (5.9)2.0 (25.0)3.0 (12.0).170aData are presented as number (%).aPearson χ2 test. Open table in a new tab