On-table completion imaging after tibial bypass is performed more frequently in patients who ultimately require return to OR and long-term bypass revisions.

Objective: On table completion imaging (CI), using duplex ultrasonography or angiography, has been traditionally considered a critical step to assess technical defects at the time of lower extremity bypass (LEB) creation. The aim of this study was to evaluate the association of CI with postoperative short term and long-term outcomes following LEB using tibial target vessels to treat chronic limb-threatening ischemia (CLTI).

Methods: All patients who underwent tibial LEB for CLTI from 2014 to 2023 were identified from the Vascular Quality Initiative database. The study cohort was stratified based on CI utilization (duplex, angiogram, or both). The primary outcomes included 30-day mortality, in-hospital return to operating room (RTOR), and ipsilateral amputation. Secondary outcomes included 1-year mortality, amputation and bypass revision. Univariate analysis was conducted using Chi-squared for categorical variables. Multivariable logistic regression was utilized to assess the association of CI with the outcomes while adjusting for relevant baseline and operative potential confounders.

Results: The study cohort included 18,577 patients of which 6,960 (37.5%) received CI. Compared to those without CI, the CI group was younger (67.8 vs. 68.2 years, p=0.027), and had lower proportion of White patients (70.4% vs. 72.4%, p<0.001), with no significant difference in gender distribution. The risk of in-hospital RTOR was higher in CI group (18.9% vs. 17.1%, p=0.002). In-hospital amputation and 30-day mortality did not differ significantly. At 1 year, the CI group had lower mortality (8.3% vs. 9.7%, p=0.001) and amputation rate (12.7% vs. 13.8%, p=0.025), but higher rates of bypass revision (11% vs. 9.7%, p=0.003). Multivariable adjusted analysis demonstrated that CI was independently associated with 13% increase in the odds of in-hospital RTOR (AOR [95%CI]: 1.13 [1.05, 1.23], p<0.01) and 1-year bypass revision (AOR [95%CI]: 1.13 [1.02, 1.25], p=0.02). Conversely, CI was associated with 14 % decrease in the odds of 1-year mortality (AOR [95%CI]: 0.86 [0.77, 0.96], p<0.01) and 11% decrease in the odds of ipsilateral amputation (AOR [95%CI]: 0.89 [0.81, 0.97], p<0.01).

Conclusion: Completion imaging after LEB with tibial targets is independently associated with increased unplanned in-hospital return to operating room and 1-year bypass revision, likely reflecting surgeons' judgment to identify high risk tibial bypasses. CI was also linked to improved long-term outcomes, including reduced 1-year mortality and limb loss. These findings suggest that, despite higher early intervention rates, CI may play a beneficial role in optimizing long-term limb salvage and survival in patients with CLTI.