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Published on: January 18, 2018
Open bypass versus endovascular therapy in chronic limb-threatening ischemia patients with prior endovascular
Mohammed Hamouda1, Sina Zarrintan1, Sabrina Straus1
1Center for Learning and Excellence in Vascular and Endovascular Surgery (CLEVER), Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
Insights
For chronic limb threatening ischemia (CLTI) patients with prior endovascular therapy (ET), open bypass surgery shows better outcomes than repeat ET. However, outcomes are similar for patients with a prior bypass, regardless of the revascularization method used.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Regenerative Medicine
Background:
- Open bypass using great saphenous vein is optimal for chronic limb threatening ischemia (CLTI).
- Many CLTI patients have undergone prior lower extremity revascularization (bypass or endovascular therapy [ET]).
- Comparing revascularization strategies in these complex patients is crucial.
Purpose of the Study:
- To compare outcomes of open bypass versus endovascular therapy (ET) in CLTI patients with a history of prior bypass.
- To compare outcomes of open bypass versus ET in CLTI patients with a history of prior ET.
Main Methods:
- Analysis of the Vascular Quality Initiative (VQI) database (2016-2023) for CLTI patients.
- Propensity score-matched cohorts (1:1) created for patients with prior bypass and prior ET.
- One-year outcomes (mortality, major amputation, reintervention, major adverse limb events [MALE]) analyzed using Cox regression and Kaplan Meier analysis.
Main Results:
- No significant difference in outcomes between bypass and ET after a prior bypass.
- A trend towards lower one-year mortality with bypass after a prior bypass was observed (p=0.078).
- In patients with prior ET, bypass was associated with significantly lower mortality (p<0.001), reintervention (p<0.001), and MALE/death (p=0.015) compared to repeat ET.
Conclusions:
- Revascularization outcomes after a prior lower extremity bypass are similar regardless of procedure type.
- Open lower extremity bypass demonstrates superior outcomes in terms of mortality and reintervention compared to secondary ET in patients with prior ET.
- Open bypass offers better MALE-free survival than repeat ET for CLTI patients with a history of prior endovascular intervention.
Objective:
Open bypass with single segment great saphenous vein is the optimum procedure for chronic limb-threatening ischemia (CLTI). However, many CLTI patients require revascularization after a prior failed lower extremity bypass or endovascular therapy (ET). Hence in this study, we aimed to investigate outcomes of bypass vs ET in patients with prior bypass as well as in those with prior ET.
Methods:
The Vascular Quality Initiative database was queried for CLTI patients who underwent infrainguinal open or endovascular revascularization after a prior lower extremity bypass or ET from 2016 to 2023. Patients with prior ipsilateral major amputation (MA), or concomitant procedures were excluded. Two well matched (SD<0.1) propensity score-matched (PSM) cohorts (1:1) were produced for patients who underwent 1-prior bypass and 2-prior ET. Cox regression, Kaplan Meier survival analysis, and Log Rank test were used to analyze one-year outcomes of bypass vs ET in both groups. Outcomes include mortality, MA, reintervention, and major adverse limb events [MALE (reintervention or MA)].
Results:
A total of 53,793 patients were included. In the group with prior bypass, 3499 (60%) underwent ET and 2338 (40%) had another bypass. While in the prior ET group, 39,738 (82.9%) had another ET and 8218 (17.1%) had a bypass. PSM produced two well matched cohorts in each group [prior bypass 1047 pairs; prior ET 5603 pairs]. After matching, there was no significant difference in any of the outcomes between bypass and ET after a prior bypass. There was a trend of lower one-year mortality with bypass after a prior bypass (HR, 0.79; 95% CI, 0.61-1.03; P = .078]. However, in patients with prior ET, bypass was associated with lower hazard of mortality (HR, 0.82; 95% CI, 0.73-0.91; P < .001), reintervention (HR, 0.73; 95% CI, 0.63-0.83; P < .001), and MALE/death (HR, 0.91; 95% CI, 0.84-0.98; P = .015] at one year compared with ET.
Conclusions:
This real-world multi-institutional study revealed that outcomes of revascularization after a prior lower extremity bypass are not associated with procedure type. However, in patients with prior ET, open lower extremity bypass is associated with lower hazard of mortality and reintervention as well as better MALE-free survival compared with secondary endovascular intervention.
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