SLR - June 2019 - John A. Martucci

Clinical Outcomes of Bypass-First Versus Endovascular-First Strategy in Patients with Chronic Limb-Threatening Ischemia Due to Infrageniculate Arterial Disease

Reference: Dayama A, Tsilimparis N, Kolakowski S, Matolo NM, Humphries MD. Clinical Outcomes of Bypass-First Versus Endovascular-First Strategy in Patients with Chronic Limb-Threatening Ischemia Due to Infrageniculate Arterial Disease J Vasc Surg. 2019 Jan 69(1):156–163.e1. doi: 10.1016/j.jvs.2018.05.244.

Scientific Literature Review

Reviewed By: John A. Martucci, DPM
Residency Program: Beth Israel Deaconess Medical Center, Boston, MA

Podiatric Relevance: Peripheral vascular disease (PVD) plagues many patients treated by foot and ankle surgeons. Referral to a vascular surgeon may be necessary prior to nonurgent surgery. Peripheral atherosclerosis may benefit from procedures, such as angioplasties, stenting or bypass to optimize distal flow. The BASIL study (The Lancet, 2005) investigated bypass versus endovascular intervention in those with severe limb ischemia due to infrainguinal disease. The researchers found that despite which intervention was performed first, both treatment groups had similar outcomes of amputation-free survival at six months postoperatively. A later paper (J. Vasc. Surg., 2010) still noted no statistically significant difference in amputation-free survival in the BASIL study patients. While above-knee disease in vessels, such as the superficial femoral artery, is common in patients with intermittent claudication, below-knee disease is the most common in patients with chronic limb-threatening ischemia (CTLI). This retrospective cohort study sought to explore outcomes of bypass-first versus endovascular-first in patients with CTLI confined to infrageniculate disease.

Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases from 2012 to 2015 were used. Inclusion criteria were patients with CTLI and infrageniculate disease. Exclusion criteria were records missing information about revascularization technique, patients with prior above-knee arterial intervention, symptoms of claudication or any ipsilateral vascular intervention. Primary outcome measures were 30-day perioperative incidences of major adverse limb event (MALE) and major adverse cardiac event (MACE). MALEs included below-knee or more proximal amputation, and MACEs included death from any cause, including myocardial infarction and stroke. Secondary outcome measures included infections, postoperative renal insufficiency, reoperation and readmission.

Results: Of 1,355 patients with matched comorbidities, 60.6 percent underwent bypass first and 39.4 percent endovascular first. Unadjusted 30-day rate of MALE was 9.0 percent vs. 11.2 percent for bypass vs. endovascular with no significant differences in major reintervention rates between groups. Unadjusted 30-day MACE was 6.9 percent vs. 2.6 percent (bypass vs. endovascular), but there was no significant difference in 30-day mortality. No significant differences in the rates of 30-day readmission or unplanned reoperations between cohorts was observed. While bypass-first intervention was associated with lower 30-day amputation rates and a higher rate of 30-day mortality, these findings were not statistically different. The only statistically significant differences between the groups included increased wound complication (9.7 percent vs. 3.7 percent) as well as adverse cardiac event rates (3.7 percent vs. 0.9 percent) in the bypass group.

Conclusions: This study provides evidence for similar successes in the early postoperative period of endovascular or bypass for patients with CTLI due to infrageniculate arterial disease. The need for randomized controlled trials, such as BASIL-2 and BEST-CLI, is affirmed by this study. Awareness of these interventions and their successes (and failures) is helpful for foot and ankle surgeons as part of multidisciplinary limb salvage teams working with patients with CTLI.

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