Infra-inguinal bypass surgery vs endovascular revascularization for chronic limb-threatening ischemia in average- and...

Area of Science:

• Vascular Surgery
• Interventional Cardiology
• Peripheral Artery Disease

Background:

• Chronic limb-threatening ischemia (CLTI) poses significant risks for limb loss and mortality.
• Revascularization through bypass surgery or endovascular therapy (EVT) are primary treatment options.
• Risk stratification is crucial for selecting optimal treatment strategies in CLTI patients.

Purpose of the Study:

• To compare treatment outcomes of bypass surgery versus EVT in average-risk CLTI patients.
• To evaluate the efficacy of bypass surgery and EVT in high-risk CLTI patients.
• To determine the optimal revascularization strategy based on patient risk stratification.

Main Methods:

• Retrospective analysis of multicenter data (2015-2022) for infra-inguinal revascularization in CLTI patients.
• Definition of high-risk patients using the SPINACH calculator (≥5% 30-day mortality or ≤50% 2-year survival).
• Propensity score matching to compare amputation-free survival (AFS), limb salvage (LS), wound healing, and 30-day mortality between bypass and EVT groups.

Main Results:

• In average-risk patients, bypass surgery showed significantly higher 2-year AFS (78.1% vs 63.0%) and LS (94.4% vs 87.7%) rates compared to EVT (P < .001 and P = .007).
• Bypass surgery also demonstrated superior 1-year wound healing rates (88.6% vs 76.8%, P < .001) in average-risk patients; 30-day mortality was similar (0.8% for both).
• No significant differences in AFS, LS, or wound healing were observed between bypass and EVT in high-risk patients (P > .05); 30-day mortality was also similar (3.2% for both).

Conclusions:

• Bypass surgery is the superior revascularization method for average-risk CLTI patients, offering better AFS, LS, and wound healing.
• EVT serves as a feasible first-line treatment for high-risk CLTI patients, demonstrating comparable outcomes to bypass surgery.
• Risk stratification is essential for guiding the selection of bypass surgery or EVT in CLTI management.