Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease

Abstract

Background Percutaneous transluminal angioplasty +/− stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention has not been reported. We report our results with three year follow-up. Methods We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001–2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality. Results We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) vs. 69 (PTA/S) (P<.01). Mean length of stay (LOS) was 3.9 vs. 1.2 days (P<.01). Bypass grafts were used less for TASC A (17% vs. 40%, P<.01), and more for TASC C (36% vs. 11%, P<.01) and TASC D (13% vs. 3%, P<.01) lesions. There were no differences in perioperative (2% vs. 0%, NS) or 3 year mortality (9 vs. 8%, NS). Wound infection was higher with bypass (16% vs. 0%, P<.01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs. 42% - 3 years, HR 0.4, 95% CI 0.23–0.71), symptom recurrence (70% and 36% at 3 years, HR 0.37, 95% CI 0.2–0.56), and freedom from symptoms at last follow-up (83% vs. 49%, (HR 0.18, 95% CI 0.08–0.40). There was no difference in freedom from reintervention (77% vs. 66% at 3 years, NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR 2.5, 95% CI 1.4–4.4) and TASC D (HR 3.7, 95% CI 3.5–9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR 3.0, 95% CI 1.8–5) and TASC D lesions (HR 3.1, 95% CI 1.4–7). Statin use postoperatively was predictive of patency (HR 0.6 95% CI 0.35–0.97) and freedom from recurrent symptoms (HR 0.6 95% CI 0.36–0.93). Conclusions Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.

Critical Limb Ischemia: Current Trends and Future Directions

“…It has been reported that statin therapy is associated with improved infrainguinal autogenous venous graft patency, with a 3.2‐fold increased risk of graft failure in patients not on statins 52. Additionally, statin therapy is associated with reduced restenosis rates after endovascular intervention,53, 54 and reduced rates of symptom recurrence after revascularization for intermittent claudication 54. Aiello et al showed in a retrospective study in 646 CLI patients that statins can improve limb salvage rates after endovascular interventions for CLI (limb salvage 83% versus 62% at 24 months) 55.…”

Comparison between superficial femoral artery stenting and bypass surgery in severe lower-limb ischaemia : a retrospective study : cardiovascular topic

“…There are not many publications comparing femoral artery stenting and bypass surgery, and the assessment of patency and the overall results of different treatment modalities is somewhat problematic, as study designs vary considerably. [16][17][18][19] In our series, 80% of TASC II A and B lesions received stents and 76% of TASC II C and D lesions received bypasses. These figures are in keeping with those reported in previous studies.…”

“…These figures are in keeping with those reported in previous studies. 9,18,19 There is evidence that shorter lesions do well with angioplasty/ stent, while longer lesions have significantly lower patency rates. 9 The latest TASC II recommendations include an endovascular approach for shorter lesions and a bypass for longer lesions.…”

İliyak arter ve infrainguinal arter tıkayıcı hastalığında hybrid strateji

“…Some studies stated that the primary patency rate of bypass surgery was considerably higher than endovascular treatment in femoropopliteal arterial diseases [12,13]. The endovascular treatment can be the first choice in the case of poor condition [14].…”