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Surgical Bypass Summit — Session 3:
Should complications and modes of failure affect our choice? — R. Clement Darling, III, MD

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R. Clement Darling, III, MD

Patients with rest pain and shallow ulcers likely require a different treatment than patients presenting with profound tissue ischemia. Patients who present with more profound ischemia are best served by more direct blood flow to the affected area, yet surgeons are not often fully aware of the lack of blood flow in these patients.1 While endovascular therapy may appear to increase blood flow, the volume of direct blood flow may be less than what can be achieved with open bypass therapy, and may also be insufficient to meet a patient’s needs. This is reflected in the observation that approximately 60% of patients who receive a distal bypass had previous endovascular interventions. This percentage is continuing to increase because many patients who receive endovascular therapy experience recurrent complications that require surgical intervention. In addition, patients who experience failures from endovascular therapy cross over to open therapy much more aggressively than patients who experience failures from open therapy.2

No single treatment modality will cure all patients.3 As surgeons, we seek a therapy that is effective with low morbidity, low mortality, and high limb salvage rate. On one hand, poor patient selection for surgery can lead to increased morbidity. On the other hand, endovascular therapy can lead to increased limb loss via inadequate increase in perfusion. In an ideal world, patients will have the option of multiple therapies, and surgeons will acknowledge that not all patients with chronic limb ischemia are equal. Patient factors such as diabetes, renal failure, cardiac disease, obesity, and age should affect the choice of therapy.3 Using these factors, patients can be stratified such that approximately 34% are classified as “high risk” and 45% are classified as “low risk.”4


There should be a better, more concise algorithm for predicting complications from endovascular interventions. Such an algorithm will improve the ability of surgeons to inform patients about their alternatives, as well as the risks and benefits of the alternatives. Patients should also be followed closely for objective endpoints and these outcomes should be constantly evaluated.3-4 In order to achieve these goals, surgeons must perform an objective evaluation that includes an analysis of failures in order to determine changes that can lead to an improvement in patient outcomes. Surgeons must also have the training and comfort level to execute multiple therapeutic options. To achieve this, endovascular interventions may need to be implemented via a team approach that removes economic imperative as a factor in treatment selection. If surgeons do not lead the effort in making these changes, market forces may dictate better treatment selection, and third-party payers may mandate better treatment algorithms.

R. Clement Darling, III, MD, is Chief of the Division of Vascular Surgery at Albany Medical Center; President of the Vascular Group; and Director for the Institute for Vascular Health and Disease in Albany, New York. He has disclosed that he has received compensation from Gore for participating in the Summit and has received honoraria from Gore for writing this article. Dr. Darling may be reached at

    Adam DJ, Beard JD, Cleveland T, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366:1925-1934. Bradbury AW, Adam DJ, Bell J, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: a survival prediction model to facilitate clinical decision making. J Vasc Surg. 2010;51(5 Suppl):52S-68S. Rogers JH, Laird JR. Overview of new technologies for lower extremity revascularization. Circulation. 2007;116:2072-2085. Schanzer A, Goodney PP, Li Y, et al. Validation of the PIII CLI risk score for the prediction of amputation-free survival in patients undergoing infrainguinal autogenous vein bypass for critical limb ischemia. J Vasc Surg. 2009;50:769-775; discussion 775.