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

Objective: On table completion imaging (CI), using duplex ultrasound examination 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 after 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 use (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 the χ² test for categorical variables. Multivariable logistic regression was used 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 whom 6960 (37.5%) received CI. Compared with those without CI, the CI group was younger (67.8 years vs 68.2 years; P = .027) and had lower proportion of White patients (70.4% vs 72.4%; P < .001), with no significant difference in gender distribution. The risk of in-hospital RTOR was higher in the CI group (18.9% vs 17.1%; P = .002). In-hospital amputation and 30-day mortality rates did not differ significantly. At 1 year, the CI group had a lower mortality rate (8.3% vs 9.7%; P = .001) and amputation rate (12.7% vs 13.8%; P = .025), but higher rates of bypass revision (11% vs 9.7%; P = .003). Multivariable-adjusted analysis demonstrated that CI was independently associated with 13% increase in the odds of in-hospital RTOR (adjusted odds ratio [AOR], 1.13; 95% confidence interval, 1.05-1.23; P < .01) and 1-year bypass revision (AOR, 1.13; 95% confidence interval, 1.02-1.25 ; P = .02). Conversely, CI was associated with a 14% decrease in the odds of 1-year mortality (AOR, 0.86; 95% confidence interval, 0.77-0.96; P < .01) and an 11% decrease in the odds of ipsilateral amputation (AOR, 0.89; 95% confidence interval, 0.81-0.97; P < .01). Conclusions: CI after LEB with tibial targets is independently associated with increased unplanned in-hospital RTOR 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 lower 1-year mortality and limb loss rates. 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.