Achieving a Normal Perfusion State from Peroneal Bypass Impacts Limb Outcomes for Patients with Tissue Loss but Not Rest Pain

The peroneal artery is a well-established but indirect bypass target for treating chronic limb-threatening ischemia (CLTI). Attaining normal/near-normal foot perfusion after peroneal bypass remains possible with robust collateral flow. Here we evaluate the long-term limb outcomes of achieving optimal versus suboptimal foot perfusion after peroneal bypass in patients with CLTI. We analyzed a national cohort of 2220 peroneal bypasses for CLTI in the Vascular Quality Initiative from 2003 to 2018. Optimal perfusion after revascularization required either an ankle-brachial index of ≥0.9, a toe-brachial index of ≥0.7, or palpable distal pulse. Demographics, preoperative risk factors, and postoperative outcomes were compared via parametric, nonparametric, and χ2 testing. Primary bypass patency and long-term limb outcomes of freedom from major adverse limb events (MALE) and amputation-free survival (AFS) were evaluated by log-rank testing of Kaplan-Meier survival curves. There were 652 patients (29.4%) who attained optimal perfusion; patient characteristics were similar across perfusion status, with a mean age of 72.1 ± 11.3 years, 42.3% nondiabetic, 8.25% dialysis dependent, and tissue loss in 69.3%. Fewer patients achieving optimal perfusion had prior inflow (10.7% vs 13.8%; P = .05) or leg interventions (36.2% vs 41.4%; P = .02); preoperative ABIs were higher among optimal perfusion patients (median, 0.45 [interquartile range, 0.3-0.68] vs 0.4 [interquartile range, 0.25-0.6]; P < .001). Rates of major and minor amputation during index hospitalization were lower in patients achieving optimal perfusion (0.6% vs 3.3%, 11.0% vs 16.0% respectively; P < .001). Through the 5-year follow-up, primary patency did not differ by perfusion status (P = .61), or within bypass indication subsets (rest pain P = .93, tissue loss P = .54). In the entire CLTI cohort, optimal perfusion patients trended toward higher 5-year freedom from MALE (47.1% vs 41.6%; P = .07); subset analyses showed no difference by perfusion status among rest pain patients (43.6% vs 43.2%; P = .77), but optimal perfusion patients had greater freedom from MALE in tissue loss (49.1% vs 40.1% P = .04). AFS at 5 years was better in CLTI patients with optimal perfusion (62.6% vs 58.9%; P = .03) (Fig 1); no significant difference in AFS by perfusion status was seen in rest pain (80.0% vs 77.6%; P = .44), but a trend toward higher rates of AFS existed for optimal perfusion patients with tissue loss (54.9% vs 50.7%; P = .06) (Fig 2). Limb outcomes through 5 years are better in CLTI patients achieving optimal foot perfusion following peroneal bypass; while nonsignificant in rest pain, optimal perfusion appears important in tissue loss, and may suggest increased podiatric/wound care support and surveillance needs in tissue loss patients. Collateral status on preoperative angiography may reflect future likelihood of attaining optimal perfusion and allow improved limb loss counseling.Fig 2Amputation-free survival by indication and perfusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)