Endo first is not appropriate in some patients with critical limb ischemia because "bridges are burned".

Background: The aims of this study were to determine the effect of failed prior endovascular treatment (EV) on early and midterm outcomes of subsequent lower extremity open surgical (OS) bypass. Methods: Patients undergoing infrainguinal bypass for critical limb ischemia (CLI) from January 2008 to December 2011 were retrospectively reviewed. The results after first-line bypass and bypass after failure of EV treatment were compared. A total of 213 patients (65.25% men; average age, 73.30 years) underwent bypass. OS patients were then divided into 2 groups: group 1 consisted of 138 patients who underwent primary OS for CLI without prior EV (control group) and group 2 consisted of 75 patients who had OS after a failed attempt at elective EV for peripheral vascular disease. Of the 213 bypass performed, 34% had a prior infrainguinal failed EV. The primary study end points were early and 1-year major amputations and graft occlusion. The secondary outcomes included early and 1-year mortality and the level of distal revascularization. Results: Secondary patency and limb salvage rates were significantly better in group 1 up to 1 year (99% vs. 86%; P < 0.001 at 1 month and 95% vs. 76%, P < 0.05 at 12 months, respectively). Conclusions: Previous failed EV should be predictive of poor outcome in patients undergoing distal OS for CLI.