Tibio-Peroneal Bypass and
Intervention : A Historic
Perspective
DONALD L. JACOBS, MD
PROFESSOR OF SURGERY
DIRECTOR, VASCULAR SURGERY TRAINING PROGRAM
SAINT LOUIS UNIVERSITY
SAINT LOUIS, MISSOURI

Surgical treatment of critical limb ischemia
First arterial reconstructions reported in 1940’s
 aortoiliac endarterectomy
 Later femoral popliteal endarterectomy
Bypass
 Reversed vein fem-pop first reported in 1944
 Prosthetics and homografts mid 1950’s
 Refined techniques with saphenous vein reported in large
series in the early 1960’s
 70% patency at 3 yrs
 First report of femoral tibial bypass using saphenous vein in
1962
 Much lower patency

Surgical treatment of critical limb ischemia
Insitu vein bypass first reported in 1964
 Valvulatome
 Key development in the technique of insitu bypass
 Higher patency of distal bypasses reported in early 1970’s
 Femoral tibial patency of 75% at 3 years
 Limb salvage rates of > 90% at 3 years
Prosthetic bypass
 Resurgence with the development of PTFE
 Patency improved with adjunctive techniques
 Still poor results with infrageniculate bypass

Surgical treatment of critical limb ischemia
Neville, JVS 2009

Surgical treatment of critical limb ischemia
 Morbidity of bypass for CLI
 Wound healing complications
 Up to 10% severe, graft threatening wound infections, tissue necrosis
 Cardiac mobidity
 15-20% despite aggressive pre and post operative management
 Mortality of bypass for CLI
 Up to 3-5% 30 day mortality in large series
 Quality of life
 Low QOL scores
 Long term patient survival
 <50% at 5 years

Endovascular treatment of CLI
Dotter and Judkins – 1964
 First report of treatment of atherosclerotic lesion
Focal lesions
 50-70% patency at 1 year
 Not much applicability to CLI
 Adjunct to bypass
Improved coronary techniques – 1980s
 First evolution of infra-popliteal intervention
 Poor results from “spasmosity”
 Limited adaptation in practice

Endovascular treatment of CLI
Continued evolution of tools 1990’s
 Lower profile balloon, improved anticoagulation
 Initial acceptance as a role as stand alone therapy for CLI
when no alternative available
 Subintimal angioplasty series with excellent limb salvage
 Still with poor patency
 Limited success with infrapopliteal occlusions

Endovascular treatment of CLI
Current era
 Improvements in access, wires, crossing tools
 long balloons
 improved stents
 atherectomy
 Ability to treat multi-level disease
 Now accepted as the primary approach to CLI in many pts

Current trends in lower extremity
revascularization
Medicare Part B claims data
 1996 compared to 2006
 Bypass surgery
 219 down to 126/100,000 beneficiaries – 42% decline
 Endovascular interventions
 138 up to 455/100,000 beneficiaries – 230% increase
 Major amputations
 263 down to 188/100,000 beneficiaries – 29% decline
Goodney, JVS, 2009

Current trends in lower extremity
revascularization
Goodney, JVS, 2009