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Published on: November 19, 2019
Outcomes and practice patterns in patients undergoing lower extremity bypass
Jessica P Simons1, Andres Schanzer, Brian W Nolan
1Division of Vascular and Endovascular Surgery, University of Massachusetts, Medical School, Worcester, MA, USA.
Insights
Lower extremity bypass (LEB) for intermittent claudication (IC) increased, with more patients having prior endovascular interventions. Outcomes for LEB in critical limb ischemia (CLI) and IC remained excellent over seven years.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- The optimal revascularization strategy for peripheral artery disease (PAD), including critical limb ischemia (CLI) and intermittent claudication (IC), remains debated.
- Large-scale data on lower extremity bypass (LEB) outcomes are essential for guiding clinical decisions.
Purpose of the Study:
- To evaluate early and 1-year outcomes of infrainguinal lower extremity bypass (LEB).
- To analyze trends in LEB utilization, including its use after endovascular interventions, for CLI and IC.
Main Methods:
- Retrospective analysis of the Vascular Study Group of New England database (2003-2009).
- Identification of 2907 infrainguinal LEB procedures.
- Primary endpoint: 1-year amputation-free survival (AFS). Secondary endpoints: in-hospital mortality and morbidity.
- Trend analyses stratified by indication (CLI vs. IC) and prior interventions.
Main Results:
- LEB for IC increased from 19% to 31% (P < .0001) between 2003 and 2009.
- Proportion of LEBs performed after prior endovascular intervention rose significantly for both CLI (11% to 24%) and IC (13% to 23%).
- In-hospital outcomes and 1-year AFS remained stable and excellent for both IC and CLI indications.
Conclusions:
- Significant shifts in LEB patient selection and treatment pathways occurred between 2003 and 2009.
- Increased utilization of LEB for IC and a greater likelihood of prior endovascular intervention preceding bypass were observed.
- LEB continues to demonstrate excellent in-hospital and 1-year outcomes for both CLI and IC.
Background:
The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions.
Methods:
The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication.
Results:
Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10).
Conclusions:
Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS.
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