Endo First Is Not Appropriate in Some Patients with Critical Limb Ischemia because ‘‘Bridges Are Burned’’ Francesco Spinelli, 1 Narayana Pipit o, 2 Eugenio Martelli, 3 Filippo Benedetto, 2 Giovanni De Caridi, 2 Domenico Spinelli, 2 and Francesco Stilo, 1 Rome, Messina and Sassari, Italy 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. INTRODUCTION National estimates of both endovascular procedures (EV) and open surgical (OS) procedures for critical limb ischemia (CLI) are conflicting and are often confounded by the inclusion of claudication, as re- ported by Sachs et al. 1 in more than 500,000 pa- tients. For limb-threatening ischemia, the number of patients undergoing EV exceeded OS by 40%. In addition, a certain number of angioplastied segments (up to 10%) reoccluded over time, which often required further interventions, which led to deteriorating distal arteries and eventually led to se- vere CLI. 2e5 The selection criteria used to determine the method of revascularization are generally based on the general health of the patient, the morphology of the lesions, the extent and location of tissue loss, and the availability of an autologous vein. Presented at XXXIX Veith Congress, November 13e17, 2012. F.S. and F.S. contributed equally to this work. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. 1 Division of Vascular Surgery, University of Campus Bio-Medico, Rome, Italy. 2 Division of Vascular Surgery, Department of Cardiovascular and Thoracic Sciences, University of Messina, Messina, Italy. 3 Division of Vascular Surgery, University of Sassari, Sassari, Italy. Correspondence to: Francesco Stilo, MD, PhD, Division of Vascular Surgery, University of Campus Bio-Medico, via Alvaro del Portillo, Roma, Italy; E-mails: frastilo@hotmail.com or f.stilo@unicampus.it Ann Vasc Surg 2015; 29: 272–277 http://dx.doi.org/10.1016/j.avsg.2014.09.032 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: May 22, 2014; manuscript accepted: September 23, 2014; published online: November 26, 2014. 272