Multilevel bypass grafting: is it worth it?

Background: Traditionally, multilevel arterial disease has been treated with an inflow procedure only but simultaneous multilevel bypass graft procedures have been attempted. However, these procedures are potentially high risk. We report our single-center experience of performing multilevel bypass grafts over the last 15 years. Methods: We retrospectively identified patients undergoing simultaneous aortoiliac and infrainguinal bypasses between January 1996 and January 2011 at a single district general hospital. Results: There were 32 multilevel procedures performed. Indication for surgery was acute ischemia in 10 (31.3%), critical ischemia without tissue loss in 10 (31.3%), with tissue loss in 10 (31.3%), and claudication in 2 (6.3%). In 23 (71.9%) cases inflow was restored using a direct iliofemoral or aortofemoral reconstruction. In the remaining 9 (28.1%), an extra-anatomic bypass was constructed. Two (6.3%) patients died within 30 days of surgery. Twenty-nine (90.6%) patients survived to discharge. Twenty-eight patients (87.5%) were alive 1 year after surgery. Limb salvage was 96.9%, 85.7%, and 75.9% at 30 days, 1 year, and 5 years, respectively. Twelve (37.5%) patients required a total of 19 further ipsilateral vascular procedures. Conclusions: Our results demonstrate that multilevel bypass procedures can be performed with good long-term outcomes and acceptable mortality, in what is typically a high-risk group with extensive comorbidities. In patients with severe critical limb ischaemia and tissue loss, who have a combination of aortoiliac and infrainguinal disease, there are significant benefits to a primary multilevel grafting procedure.