慢性虚血性下肢患者における開バイパス術と血管内治療の比較：過去の血管内治療歴のある患者

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.

The Vascular Quality Initiative (VQI) database were 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, major amputation (MA), reintervention, and major adverse limb events [MALE (reintervention or MA)].

A total of 53,793 patients were included. In the group with prior bypass, 3,499 (60%) underwent ET and 2,338 (40%) had another bypass. While in the prior ET group, 39,738 (82.9%) had another ET and 8,218 (17.1%) had a bypass. PSM produced two well matched cohorts in each group [prior bypass 1,047 pairs; prior ET 5,603 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=0.078]. However, in patients with prior ET, bypass was associated with lower hazard of mortality [HR=0.82, 95%CI 0.73-0.91, p<0.001], reintervention [HR=0.73 95%CI 0.63-0.83, p<0.001], and MALE/death [HR=0.91, 95%CI 0.84-0.98, p=0.015] at one year compared to ET.

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 to secondary endovascular intervention.