Introduction: The optimal revascularization strategy for patients with severe leg ischemia remains uncertain. The purpose of this study was to compare outcomes of bypass surgery, and angioplasty in isolated below-the-knee lesions.

Methods: Patients with ulcers or toe gangrenes undergone below-the-knee bypass surgery or angioplasty from January 2010 to December 2016 were included.  Amputation free survival (AFS) and overall survival (OS) were assessed using the Kaplan-Meier and cox-regression tests. 

Results: 88 patients were included in this study, of which 43 were bypass surgery patients and 45 were endovascular interventions. Mean age in bypass group was 73.1 (±7.1), and in angioplasty group was 73.9 (±7.2) years old. There were no significant differences in sex, diabetes, hypertension, history of smoking, history of stroke, and renal insufficiency between two groups. AFS was 43.4 (±8.5) months in bypass group, and 39.8 (±8.9) months in angioplasty group that is significantly better in bypass group (P=0.05). OS was 49.6 (±10.6) months in bypass group and 46.2(±11.7) months in angioplasty group that did not differ statistically significant (P=0.32).  

Conclusion: There is a significant difference in AFS, but not OS, in bypass group. We recommend bypass surgery in all patients with severe leg ischemia except those with multiple comorbidities and those whose vein is not adequate for bypass.