Femoropopliteal tibial bypass: what price failure?

The consequences of failure in 235 femoropopliteal and femorotibial operations are reviewed and compared with the benefits of success so that an accurate perspective of risk-benefit analysis can be achieved. In 72 operations performed for claudication, 10 grafts thrombosed early. The cost included nine reoperations to achieve eight patent grafts and a 12 day average increase in hospital stay. There were no deaths. The benefit obtained was 70 of 72 (97 percent) asymptomatic limbs. In 163 grafts placed for limb salvage, there were 58 initial thromboses. Reoperation in 28 produced an additional 14 patent grafts. The cost of thrombosis was an increase in mortality from 5.6 to 10.7 percent, a 12 day average increase in hospital stay, and raising of preoperative predicted amputation level from below to above the knee in 11 patients with thrombosed grafts whose distal anastomoses were below the knee. This contrasted with a 73 percent limb salvage rate in 104 patients whose preoperative predicted amputation level was below the knee, and a 54 percent limb salvage and a 12 percent lowering of amputation level in 39 patients whose preoperative amputation level was above the knee. Of patients with patent grafts, 89 percent achieved limb salvage. We conclude that the benefits of success in attempted vascular reconstruction for threatened limb loss far outweigh the risks of failure and that the combined results were far superior to the expected outcome in comparable patients undergoing primary amputation.