Inverted T bypass: a solution for distal revascularization in the absence of an adequate autologous vein graft

Abstract Introduction: Peripheral arterial disease has become a worldwide problem, with chronic limb-threatening ischemia(CLTI) being its most extreme manifestation. Recently, endovascular strategies evolved and became the first approach in many revascularization procedures. However, infrapopliteal (IP) disease is still a therapeutic challenge. This study aims to present a surgical technique, named inverted T bypass, that can be applied to patients with: an IP artery with poor collateralization to the foot, an infra-malleolar artery with poor runoff and availability of only a short venous graft. Methods: A single-center retrospective analysis of all patients submitted to inverted T bypass. The end points of the present study were limb-based patency (LBP), primary patency (PP) and secondary patency (SP) rates, freedom from CLTI, recurrence of CLTI, freedom from major index limb amputation, amputation free-survival, and overall survival. Results: A total of twenty-five patients with CLTI (68% male) with a median age of 77 years were submitted to 25 inverted T bypasses. The median follow-up was 25 months (interquartile range of 32). Twenty-one preoperative angiographies were performed. Severe femoropopliteal (FP) and IP anatomic patterns (GLASS FP and IP grade 4) were predominant (57% and 86%, respectively) with 100% of limbs classified as GLASS stage III. Three patients (12%) had previously failed endovascular treatment. LBP, PP and SP were, respectively, 75%, 75% and 79% at 1 year, and 61%, 61% and 64% at 2 years. After one year, 86% of the limbs were free from CLTI and 79% of them remained without recurrences during a follow-up of 2 years. Eighty-one percent of the patients were free from major index limb amputation at 2 years. Conclusion: The inverted T bypass is a creative surgical solution for CLTI patients with poor runoff and lacking an adequate venous graft. The results are promising, rendering this technique a viable option for distal and ultra-distal revascularization in complex cases.