IP02 - Effect of Prior Endovascular Intervention on Limb Salvage Outcomes After Infrainguinal Bypass for Chronic Limb-Threatening Ischemia

Objectives: A substantial proportion of patients with chronic limb-threatening ischemia (CLTI) undergo multiple revascularization strategies, and when infrainguinal bypass becomes necessary, there is concern that prior ipsilateral endovascular intervention may influence outcomes. This study assessed whether prior endovascular intervention affects limb salvage and amputation-free survival after infrainguinal lower extremity bypass in patients with CLTI.

Methods: We performed a retrospective cohort study at a tertiary referral center including all patients who underwent infrainguinal lower extremity bypass for CLTI between January 2020 and July 2025. Limbs were analyzed as independent units. Patients were stratified into a bypass-first group, defined as limbs undergoing infrainguinal bypass as the first therapeutic revascularization, and an endovascular-first group, defined as limbs undergoing bypass after prior ipsilateral therapeutic endovascular intervention. Baseline demographics, comorbidities, Rutherford classification at the time of bypass, bypass anatomy, and postoperative outcomes were collected according to Society for Vascular Surgery reporting guidelines. The primary outcome was limb salvage following bypass. Secondary outcomes included amputation-free survival and reintervention.

Results: A total of 348 infrainguinal bypasses were included, comprising 243 bypass-first limbs and 105 endovascular-first limbs. Baseline demographics and comorbidities were largely comparable between groups, although diabetes mellitus was more prevalent in the endovascular-first cohort. Preoperative limb threat severity was similar, with comparable distributions of Rutherford classes 4-6 at the time of bypass. Mean follow-up was 4.19 years. Among endovascular-first patients, the mean interval from the first endovascular intervention to bypass was approximately 160 days; 82 patients had undergone one prior intervention, 18 had undergone 2, and 5 had undergone three prior interventions. Limb salvage at 1 year was 80.2% in the bypass-first group and 80.1% in the endovascular-first group (p = 0.81), and at 4 years was 75.7% vs. 73.3% (p = 0.74) (Figure 1). Amputation-free survival at 1 year was similarly comparable between groups (69.5% vs 67.6%, p = 0.86) (Figure 2). Within the endovascular-first cohort, mean limb salvage at 1 year did not differ significantly between patients undergoing bypass after one prior endovascular intervention versus two or more prior interventions (361.6 vs 359.96 days; p = 0.788).

Conclusions: Among patients with CLTI who ultimately required infrainguinal bypass, prior ipsilateral endovascular intervention was not associated with inferior limb salvage or amputation-free survival. When bypass was performed at comparable disease severity, outcomes were equivalent regardless of prior endovascular exposure, supporting a flexible, individualized revascularization strategy in contemporary CLTI management.