Proximal percutaneous balloon angioplasty and distal bypass for multilevel arterial occlusion. Veterans Administration Cooperative Study No. 199.

Multiple sites of atherosclerotic occlusion in high risk patients may be treated by angioplasty of the iliac obstruction and distal reconstruction. We report 18 male patients with symptomatic peripheral vascular disease in whom proximal iliac percutaneous transluminal angioplasty was combined with femoropopliteal bypass (11), femorotibial bypass (2), or femorofemoral bypass (5). There were no operative deaths. The pretreatment ankle brachial index of 0.40 +/- 0.04 was increased to 0.64 +/- 0.04 by discharge (p = 0.0001), and remained significantly increased through 27 months (0.65 +/- 0.07) (p = 0.0001). During the follow-up period of 2-57 (mean 27 months) one dilated iliac artery required repeated percutaneous transluminal angioplasty and revision of the femoropopliteal bypass at three months. Two late amputations of study limbs occurred at two years and three years due to progression of distal disease in the infrapopliteal segment. Four patients died during the follow-up period of ischemic heart disease (3) and lung carcinoma (1). Life table analysis shows a 76% success rate for the combined procedures at two years. In selected, high risk patients, proximal iliac dilatation and distal bypass is an acceptable alternative reconstruction for multilevel occlusion.