Below-knee endovascular interventions have better outcomes compared to open bypass for patients with critical limb ischemia

Abstract

Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008-2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60-0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80-1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44-1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease.

Single arm retrospective study of bioresorbable vascular scaffolds to treat patients with severe infrapopliteal arterial disease

“…7 On the other hand, traditional open bypass below the knee is associated with increased perioperative risk with some studies reporting reduced patency rates compared to endovascular intervention. 8 Traditional metallic stents have detrimental effects on vessel physiology. Metallic stents remain in the vessel indefinitely and impair vessel vasomotor tone, remodeling, and autoregulation.…”

Current Status of Arterial Revascularization for the Treatment of Critical Limb Ischemia in Infrainguinal Atherosclerotic Disease

“…In this study, which includes a total of 2,566 cases, authors compared the procedures in terms of the rates of 1-year primary patency, major amputation, and mortality, and they found lower 1-year primary patency rate in bypass surgery patients while similar major amputation and mortality rates of both revascularization procedures. 53 Indirect comparisons of endovascular interventions 25,55 and bypass surgery using a venous conduit 56 demonstrated similar outcomes with respect to 1-year limb salvage and mortality rates in the treatment of CLI, both ranging from 85 to 90%, however, a higher requirement of re-interventions following endovascular treatment. 57 This increased rate of re-intervention is associated with an increase in the number of endovascular interventions in case of both intermittent claudication and CLI over the years, which outnumbers the decrease in open surgical procedures.…”

“…Many comparative studies have been conducted on this issue, and the evidence of whether endovascular or surgical therapy is superior for patients with CLI has been sought for last years. 22,23,[49][50][51][52][53] The first report of the BASIL trial revealed that amputation-free survival and quality-oflife rates were similar in both endovascular and open surgery groups at 6 months. 22 In the long-term, nevertheless, open bypass surgery has provided a significantly increased overall survival benefit of nearly 7 months for patients who survived over 2 years.…”

Hemodialysis patients have worse outcomes after infrageniculate revascularization procedures

“…3,4 However, others suggest that outcomes are similar with both approaches or even superior for PVI. [5][6][7] The discrepancies in these findings are likely reflective of the different populations being studied. Certain patient subgroups have different outcomes after lower extremity revascularization than others.…”