Early Surgical Outcome after Failed Primary Stenting for Lower Limb Occlusive Disease

Purpose: To evaluate the early results of revascularization after failed primary stent placement for lower limb occlusive disease. Methods: A retrospective review was conducted of 25 consecutive patients (16 men; mean age 65 years, range 32–89) treated between January 2001 to October 2003 for infrainguinal stent failure at a median 6.6 months (range 3–60) after primary stent implantation (27 femoropopliteal and 20 popliteal-crural) at referring hospitals. All surgical procedures for stent failure were performed at tertiary centers. The results of bypass grafting for failed stenting were compared to a contemporaneous cohort of patients undergoing primary bypass surgery performed by the same surgeons. Results: At the time of admission, 22 stents were thrombosed, and 3 patent stents presented with >50% in-stent stenosis. Twenty patients had 7 femoropopliteal or 9 femorodistal vein bypasses and 4 reconstructions of the common femoral or profunda femoris artery. Four patients had 3 primary amputations and 1 lumbar sympathectomy. One patient with claudication was treated conservatively. Procedure-related complications were observed in 40%; 30-day mortality was 4% (1/25). Early (30-day) graft thrombosis occurred in 6 (30%) of 20 arterial reconstructions, necessitating 8 secondary amputations (44% [11/25] overall amputation rate). A total of 47 surgical procedures were performed in the 24 surviving patients (median 2 operations per patient, range 1–9) over an 11-month period (range 1–57). Primary patency rates at 30 days and at 6 and 12 months were 67%, 44%, and 33%, respectively, in the poststent bypass cohort versus 98%, 96%, and 88%, respectively, in a contemporaneous group of patients treated with primary bypass grafting. Conclusions: Failed stents in lower limb arteries often require distal reconstructive bypass surgery, which is associated with high complication rates and poor outcome, including major amputations. There is no scientific evidence to support stenting below the inguinal ligament.