1. Entretiens Vasculaires de Québec 2014
G.Nourissat MD

2. Context
2

3. Context/90’: Outcomes of bypass
surgery
Dalman, RL, Taylor, LM Jr. Infrainguinal revascularization procedures. In: Basic
Data Underlying Clinical Decision Making in Vascular Surgery, Porter, JM, Taylor,
LM, Jr (Eds), Quality Medical Publishing, St. Louis 1994. p.141.
3
P. Patency AK 1 year FU 4 y FU
Saphenous 84% 69%
PTFE 79% 60%
BK 1 year FU 4 y FU
C.P.Patency 90% 75%
S.Patency PTFE 68% 40%

4. Context/2005
4
RECOMMENDATIONS
Class I
1 Bypasses to the above-knee popliteal artery should be constructed with autogenous saphenous vein when possible. (Level of
Evidence: A)
2 Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible. (Level of Evidence: A)
3 The most distal artery with continuous flow from above and without a stenosis greater than 20% should be used as the point of
origin for a distal bypass. (Level of Evidence: B)
4 The tibial or pedal artery that is capable of providing continuous and uncompromised outflow to the foot should be used as the site
of distal anastomosis. (Level of Evidence: B)
5 Femoral-tibial artery bypasses should be constructed with autogenous vein, including the ipsilateral greater saphenous vein, or if
unavailable, other sources of vein from the leg or arm. (Level of Edence:B)
6 Composite sequential femoropopliteal-tibial bypass and bypass to an isolated popliteal arterial segment that has collateral outflow
to the foot are both acceptable methods of revascularization and should be considered when no other form of bypass with adequate
autogenous conduit is possible. (Level of Evidence: B)
7 If no autogenous vein is available, a prosthetic femoral-tibial bypass, and possibly an adjunctive procedure, such as arteriovenous
fistula or vein interposition or cuff, should be used when amputation is imminent. (Level of Evidence: B)
Class IIa
1 Prosthetic material can be used effectively for bypasses to the below-knee popliteal artery when no autogenous vein from ipsilateral
or contralateral leg or arms is available. (Level of Evidence: B)

5. Context/2007
5

6. Context: BASIL / 2005
6

7. What about latest outcomes in
literature?
7

8. 2012/ ssGSV bypass
8
n=1100 ssGVS aaVG
1 year 3 years 1 year 3 years
PP 74.4% 67.1% 53.7% 42% p<0.0001
aPP 82.8% 78.2% 67.2% 57.8% p<0.0001
SP 84.8% 80.8% 69.9% 61.4% p<0.0001
LS 88.9% 86.9% 83% 77.2% p<0.0001

9. 2005/Outcomes of bypass
surgery: alternate conduit
9
SP LS

10. 2008/ perigeniculate bypass
10
Limb salvage :90,2% (3 years)
Survival 63,9% (3 years)
— Primary patency
--- Assisted primary patency
Primary patency 65,7%
(3 ans)

11. 2014/Outcomes of bypass
surgery: angiosomal concept
Limb Salvage 1 year 3 year 5 year
Angiosomal group 91% 65% 58%
Indirect group 66% 24% 18%
11
P<0.001

12. 2010/ Outcomes of infragenicular
bypass
5 years
follow-up
N= 1023 Leg salvage Survival Freedom
from surgical
revasc.
PTA 262 75.3% 47.5% 85.3%
Bypass 761 76% 43.3% 91.4%
p< 0.001
12

13. BASIL / 2010
13

14. 2011/ Outcomes of surgery
bypass and comorbities
14

15. EBM with endovascular therapy
approach first?
 Tasc II= level C
 Guidelines 2013* AHA = level B
 Meta-analyse Jens 2014**= level C
15
*2013/ Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011
ACCF/AHA Guideline Recommendations) A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guide
Developed in Collaboration With the Society for Cardiovascular Angiography and Interventions, So
of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery
**Randomized Trials for Endovascular Treatment of Infrainguinal Arterial Disease: Systematic
Review and Meta-analysis (Part 2: Below the Knee).
Jens S1, Conijn AP2, Koelemay MJ2, Bipat S3, Reekers JA3.
Eur J Vasc Endovasc Surg. 2014 May

16. Bypass indication in 2014
?
 Anatomic TASC D lesion +/- B or C
 Autogenous veins suitable
 Life expectancy > 2years*
 PTA failure/ Restenosis =Not anymore!?
 Trained center
 Target angiosomal zone respected
16
*2013/ Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommen
A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Gu
Developed in Collaboration With the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology,
for Vascular Medicine, and Society for Vascular Surgery

17. Bypass indication in 2014 ?
 BEST-CLI-Trial
17

18. Merci
18