Femoropopliteal bypass shows reintervention benefit over endovascular therapy for advanced premature PAD

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Tanner I Kim

Femoropopliteal bypass is associated with decreased reinterventions at one year compared to endovascular therapy in patients with advanced premature peripheral arterial disease (PAD). This is the primary conclusion of Tanner I Kim (Yale School of Medicine, New Haven, USA) and colleagues, writing in an article recently published online in the Journal of Vascular Surgery.

The authors add, however, that bypass surgery is associated with increased perioperative morbidity and hospital length of stay compared with endovascular therapy and that both revascularisation techniques “seem to be equally effective in terms of limb preservation and survival”. Looking ahead, they suggest that studies accounting for costs of increased perioperative morbidity and hospital stay as well as reinterventions are required to determine which strategy is more cost-effective.

Patients who present with PAD at age ≤50 are considered to have the condition prematurely, Kim and colleagues relay, noting that such patients have poor outcomes with open and endovascular lower extremity revascularisation. “It is unclear if either strategy is associated with better outcomes as comparative studies are limited to case series in this patient population”, they write, summarising the literature.

In order to address this research gap, the investigators aimed to compare outcomes of patients with premature PAD undergoing bypass or endovascular revascularisation for advanced femoropopliteal disease. They hypothesised that open bypass would provide “superior long-term outcomes” when compared with endovascular intervention.

The investigators reviewed all patients with premature PAD undergoing isolated femoropopliteal lower extremity revascularisation in the Vascular Quality Initiative (VQI) infrainguinal bypass and peripheral vascular intervention files from 2003 through 2019, they detail in JVS, before analysing one-year reintervention, patency, major amputation, and mortality outcomes.

Kim et al communicate that there were 902 patients who underwent isolated femoropopliteal endovascular interventions, and 1,636 patients who underwent femoropopliteal bypass. In terms of comorbidities, they detail that patients undergoing endovascular intervention were more likely to have diabetes (68.9% vs. 54%; p=0.001), coronary artery disease (31% vs. 23%; p<0.001), renal failure requiring dialysis (14.2% vs. 7.2%; p<0.001), and claudication (45.1% vs. 36.3%; p<0.001) compared with patients undergoing bypass. After propensity matching, the authors detail that there were 466 patients in each group with no significant differences in baseline characteristics and therefore eligible for inclusion in the study.

“Perioperative morbidity was higher with femoropopliteal bypass compared with endovascular intervention”, the authors report, noting respective rates of 12% and 7.9%, and a p-value of 0.083. At one year, however, the authors reveal that patients undergoing femoropopliteal bypass were less likely to require reintervention (17% vs. 25.2%; p=0.012). Finally, they reveal no difference in major amputation (7.7% vs. 7.9%; p=0.928) or mortality (5.2% vs. 5.2%; p=1) at one year.

In the discussion of the study limitations, Kim and colleagues recognise that the outcomes were limited to only one-year follow-up, and suggest that “longer term outcomes may have demonstrated additional differences between those treated with bypass and endovascular intervention”. Furthermore, they acknowledge that the VQI does not capture the frequency of reinterventions, which is “particularly important in this patient population as they are likely to live longer and remain at high risk of failure”. They urge that newer measures to assess frequency of reintervention should be included in studies of comparative effectiveness of revascularisation.


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