Effectiveness of Lower Extremity Revascularization

Study Questions:

What is the safety and effectiveness of lower extremity bypass (LEB) and peripheral endovascular interventions (PVIs) for patients with symptomatic claudication and critical limb ischemia (CLI)?

Methods:

Using community-based clinical registries at two large integrated healthcare centers, 883 patients undergoing PVI and 975 patients undergoing LEB between 2005 and 2011 were evaluated. Rates of target lesion revascularization (TLR) and complications were assessed based on the type of indication and the clinical disease state (claudication vs. CLI). Propensity methods were used to adjust for treatment selection bias.

Results:

Rates of TLR were higher for PVI patients as compared to LEB patients presenting with claudication at 1 year (12.3% ± 2.7% vs. 5.2% ± 2.4%, p < 0.001) and at 3 years (19.3% ± 3.5% vs. 8.3% ± 3.1%, p < 0.001). Similar results were seen for CLI patients at 1 year (19.1% ± 4.8% vs. 10.8% ± 2.5%, p < 0.001) and at 3 years (31.6% ± 6.3% vs. 16.0% ± 3.2%, p < 0.001). Compared to PVI, LEB was associated with increased rates of complications at 30 days post-procedure (37.1% vs. 11.9%, p < 0.001) without any difference in rates of amputation. Similar findings were seen after propensity score adjustment.

Conclusions:

The authors concluded that for patients with claudication or CLI, PVI was associated with fewer procedural complications, but higher rates of revascularization as compared to LEB. The authors also noted no difference in the rate of amputation between the two management strategies.

Perspective:

The authors leverage two large, integrated healthcare system databases to describe the effectiveness and safety of endovascular versus surgical revascularization for symptomatic peripheral arterial disease. While endovascular approaches are commonly praised for fewer periprocedural complications, surgical bypass was shown to require fewer target lesion revascularization procedures. While the authors performed a detailed adjustment for selection bias, these data are still observational in nature and subject to potential unmeasured confounders, such as the availability of bypass targets or the suitability of venous bypass conduit for each patient. It is remarkable how frequently revascularization procedures are required, particularly for patients with CLI. Clinicians and patients should discuss these safety and efficacy outcomes along with the appropriateness and feasibility of both revascularization techniques when deciding on the best treatment decision for symptomatic peripheral arterial disease.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Vascular Medicine

Keywords: Amputation, Cardiac Surgical Procedures, Coronary Artery Bypass, Endovascular Procedures, Intermittent Claudication, Lower Extremity, Peripheral Arterial Disease, Peripheral Vascular Diseases, Secondary Prevention


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