Editor's Choice - Infra-inguinal Endovascular Revascularisation and Bypass Surgery for Chronic Limb Threatening
Jean-Baptiste Ricco1, Richard J Roiger2, Fabrice Schneider3
1Department of Clinical Research and Vascular Surgery Service, Poitiers University Hospital, Poitiers, France.
Insights
Lower limb bypass surgery shows superior long-term effectiveness for chronic limb-threatening ischemia (CLTI) compared to endovascular treatment (EVT). Bypass offers better amputation-free survival and wound healing rates, crucial for managing CLTI patients.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- Chronic limb-threatening ischemia (CLTI) poses a significant risk of amputation and mortality.
- Revascularization strategies, including bypass surgery and endovascular treatment (EVT), are critical for limb salvage.
- Comparing the long-term efficacy of these interventions is essential for optimal patient management.
Purpose of the Study:
- To compare the long-term efficacy of lower limb bypass surgery versus endovascular treatment (EVT) in patients with CLTI.
- To evaluate amputation-free survival (AFS) rates as the primary outcome.
- To assess wound healing and major adverse events as secondary outcomes.
Main Methods:
- Retrospective, multicentre study of patients with CLTI undergoing infra-inguinal bypass or EVT.
- Propensity score matching was used to create comparable groups.
- Primary outcome: amputation-free survival (AFS) at five years. Secondary outcomes: wound healing at six months, major adverse events.
Main Results:
- Lower limb bypass surgery demonstrated significantly better AFS at five years (60.5%) compared to EVT (35.3%).
- Bypass group had significantly higher wound healing rates at six months.
- Major amputation rates were lower in the bypass group (25.8%) versus EVT (36.0%).
- EVT group had a shorter median length of stay (4 days vs. 8 days).
Conclusions:
- Lower limb bypass surgery offers superior long-term efficacy for CLTI patients compared to EVT.
- Bypass surgery provides a significantly higher probability of amputation-free survival and wound healing.
- While EVT offers a shorter hospital stay, bypass surgery remains a more effective revascularization strategy for limb salvage in CLTI.
Objective:
The aim of this study was to compare the long term efficacy of lower limb bypass with that of endovascular treatment (EVT) in patients with chronic limb threatening ischaemia (CLTI).
Methods:
This retrospective, multicentre study evaluated the outcomes of patients with CLTI who underwent first time infra-inguinal bypass or EVT. The primary outcome was to compare amputation free survival (AFS) rates between the two propensity score matched groups. The secondary outcome was to compare wound healing within the first six months. Major adverse events were compared according to the type of revascularisation.
Results:
Overall, 793 patients fulfilled the eligibility criteria, from whom 236 propensity score matched pairs were analysed. The mean follow up was 52 months. The 236 bypass procedures included 190 autogenous bypass grafts (80.5%), 151 (64.0%) of which were infrapopliteal. Among the 236 EVT procedures, the target lesion was the femoropopliteal segment in 81 patients (34.3%), the femoropopliteal and infrapopliteal segments in 101 patients (42.8%), and the infrapopliteal segment in 54 patients (22.9%). AFS was significantly better in the bypass group at five years (60.5 ± 3.6%) compared with the EVT group (35.3 ± 3.6%) (p < .001). Major amputation occurred in 61 patients (25.8%) in the bypass group and 85 patients (36.0%) in the EVT group (HR 0.66, 95% CI 0.47 - 0.92; p = .014). The probability of healing was significantly better in the bypass group at six months compared with the EVT group (p = .003). The median length of stay was shorter for the EVT group (4 days) than for the bypass group (8 days) (p = .001). Urgent re-intervention and re-admission rates were high and did not differ significantly between the groups.
Conclusion:
This study has shown that lower limb bypass surgery offered a significantly higher probability of AFS and wound healing compared with EVT in patients with CLTI.
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