Distal bypass may reduce major amputations for chronic limb-threatening ischemia by >50% compared with endovascular therapy alone

Introduction Our department was established in July 2023. Before our arrival, approximately 200 endovascular therapy procedures for lower extremity artery disease were performed annually by cardiologists, but distal bypass was not available. During the first 12 months, our department performed 35 distal bypass procedures. We aimed to evaluate the impact of introducing distal bypass in our high-volume endovascular therapy center. Methods We retrospectively reviewed patients who underwent major amputation at our institution between August 2021 and March 2025. The study period was divided into two groups: the Bypass group (after August 2023) and the Control group (before July 2023). We compared the monthly number of major amputations between the groups. Results A total of 130 patients with 147 limbs who underwent major amputation were included in this study. There were no differences in age or sex distribution between groups. There were no significant differences in the overall number of major amputations ( P = .082) or amputations due to nonchronic limb-threatening ischemia causes ( P = .68). However, the number of major amputations for chronic limb-threatening ischemia significantly decreased in the Bypass group (1.96 vs 0.95 per month, P = .030). Discussion The absence of differences in nonchronic limb-threatening ischemia–related amputations between groups indicates that the observation periods were comparable. Conversely, chronic limb-threatening ischemia–related amputations decreased by 52% following the introduction of distal bypass. This finding indicates that endovascular therapy alone may not salvage all limbs that could be saved with distal bypass.We also established the FHU Limb Salvage Center and strengthened multidisciplinary collaboration among vascular surgeons, cardiologists, dermatologists, plastic surgeons, orthopedic surgeons, and allied health professionals. This multidisciplinary approach likely contributed to improved limb salvage outcomes. Despite advancements in endovascular therapy, the number of surgeons trained in distal bypass continues to decline. It is essential to preserve and pass on distal bypass expertise to the next generation. Conclusions Even in a high-volume endovascular therapy institution, distal bypass may reduce major amputation procedures for chronic limb-threatening ischemi by >50% compared with endovascular therapy alone. The surgical skill of performing distal bypass must be maintained and passed on to future generations.