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Published on: September 22, 2020
A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in
John Futchko1, Patricia Friedmann2, John Phair1
1Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York.
Insights
For chronic limb-threatening ischemia (CLTI), an endovascular-first approach shows lower amputation rates and shorter hospital stays compared to nonautologous conduit bypass. This strategy may be preferable when autologous conduits are unavailable.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Endovascular Therapies
Background:
- Chronic limb-threatening ischemia (CLTI) often requires revascularization.
- Autologous vein bypass is the gold standard but frequently unavailable.
- Nonautologous prosthetic conduits (NAC) are an alternative, but outcomes data are crucial.
Purpose of the Study:
- To compare limb salvage and survival rates between endovascular intervention and open bypass using NAC in patients with CLTI undergoing first-time revascularization.
- To evaluate amputation-free survival (AFS), reintervention rates, patency, and overall survival.
Main Methods:
- Retrospective review of 125 patients (2009-2016) undergoing first-time revascularization.
- Cohorts: endovascular intervention (n=65) vs. open bypass with NAC (n=60).
- Propensity scoring for matched analysis; outcomes assessed using Kaplan-Meier and Cox models.
Main Results:
- Endovascular intervention showed lower 30-day amputation rates (1.5% vs. 10%) and shorter hospital stays (1 vs. 9 days) compared to NAC bypass in matched analysis.
- The endovascular group trended towards higher 2-year AFS (76% vs. 65%), though not statistically significant.
- Nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, P=0.07).
Conclusions:
- An "endovascular first" strategy provides better perioperative outcomes for CLTI patients.
- Endovascular intervention offers comparable amputation-free survival to NAC bypass.
- This approach is a potentially preferable option when autologous conduits are not available.
Objectives:
Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention.
Methods:
We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models.
Results:
A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P < 0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization.
Conclusions:
An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.
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