The impact of infrainguinal endovascular interventions on the results of subsequent femoro-tibial bypass procedures: A retrospective cohort study

A systematic review and meta-analysis of primary bypass surgery compared with bypass surgery after endovascular treatment in peripheral artery disease patients

OBJECTIVE

Both bypass surgery and endovascular treatment are well-recognized interventions for the treatment of peripheral artery disease; however, the effect of failed endovascular treatment on subsequent surgeries remains controversial. A systematic review was conducted to compare the outcomes of primary bypass and bypass surgery after endovascular treatment.

METHODS

Three academic databases (Embase, PubMed, and Scopus) were searched from their inception to August 2022. Two independent investigators searched for studies that reported the outcomes of primary bypass surgery and bypass surgery after endovascular treatment in patients with peripheral artery disease. Abstracts and full-text studies were screened independently using duplicate data abstraction. Dichotomous outcome measures were reported using a random-effects model to generate a summary odds ratio (OR) and 95% confidence interval (CI). The risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

Seventeen retrospective observational studies were selected from 3911 articles and included 8064 patients, 6252 of whom underwent primary bypass surgery and 1812 underwent bypass surgery after endovascular treatment. The mean age was 69.0 years and 61.2% (n = 4938) were male. For perioperative outcomes, the 30-day results showed no difference in mortality (OR, 0.76; 95% CI, 0.53-1.10), or amputation (OR, 0.89; 95% CI, 0.67-1.20). For short- to mid-term outcomes, primary patency did not differ at 6 months (OR, 0.98; 95% CI, 0.81-1.19), 1 year (OR, 1.12; 95% CI, 0.97-1.30), or 2 years (OR, 1.17; 95% CI, 0.85-1.61) follow-up. Amputation-free survival did not differ at 6 months (OR, 1.03; 95% CI, 0.82-1.30), 1 year (OR, 1.09; 95% CI, 0.89-1.32), 2 years (OR, 1.18; 95% CI, 0.93-1.50), or 3 years (OR, 1.09; 95% CI, 0.84-1.40) of follow-up. No significant difference was found in overall survival or second patency.

CONCLUSIONS

This meta-analysis of retrospective, nonrandomized, observational studies suggests that prior endovascular treatment of lower extremity arterial disease does not result in worse perioperative, short-term, or mid-term clinical outcomes of subsequent infrainguinal bypass surgery compared with patients without prior endovascular treatment.

Comparison of long occlusive femoro-popliteal de novo vs. previous endovascularly treated lesions managed with in situ saphenous bypass

BACKGROUND

The aim of this study was to compare two-year outcomes of de novo vs. post-endovascular lesion treatment of femoro-popliteal occlusions included in a national, multicenter, observational, prospective registry based on the treatment of critical Limb-threatening IschaeMia with infragenicular Bypass adopting in situ SAphenous VEin technique (LIMBSAVE).

METHODS

From January 2018 until December 2019, 541 patients from 43 centers have been enrolled in the LIMBSAVE registry. Of these patients, 460 were included in the present study: 341 (74.1%) with de novo lesions (Group DN) and 119 (25.9%) with post-endovascular treatment lesions (Group PE). Initial outcome measures were assessed at 30 days post-treatment. Furthermore, at 2-year follow-up, estimated outcomes of primary patency, primary assisted patency, secondary patency, and limb salvage were analyzed with Kaplan-Meier curves and compared between groups with the log-rank test.

RESULTS

Both groups were homogeneous in terms of demographic data, preoperative risk factors, and clinical presentation. However, compared to Group DN, more patients in Group PE had a great saphenous vein diameter of < 3 mm (11.1% vs. 21%; P=0.007). Intraoperatively, both groups showed similar distal anastomosis sites: below-the-knee popliteal artery (63% Group DN, 66.4% Group PE) and tibial vessel (37% Group DN, 33.6% Group PE) (P=0.3). Overall mean duration of follow-up was 11.6 months (range 1-24). At 2-year follow-up there were no differences between the two groups in terms of primary patency (66.3% Group DN vs. 74.1% Group PE, P=0.9), primary assisted patency (78.2% Group DN vs. 79.5% Group PE, P=0.2), secondary patency (85.1% Group DN vs. 91.4% Group PE, P=0.2), and limb salvage (95.2% Group DN vs. 95.1% Group PE, P=0.9).

CONCLUSIONS

The LIMBSAVE registry did not show a worsening of overall patency and limb salvages rates at the 2-year follow-up in patients undergoing in situ saphenous bypass after a failed endovascular approach for long femoro-popliteal occlusive disease. This is in contrast to what has been published in literature.

Outcomes and Fate of the Distal Landing Zone Compared Between Prosthetic and Autologous Grafts After Infra-Inguinal Graft Occlusions

Background

Due to an increasing life expectancy, more and more patients experience the failure of peripheral arterial revascularization. This study aims to investigate patients treated for the failure of infra-inguinal bypass grafts, and to investigate the interaction of different bypass materials [great saphenous vein (GSV) and polytetrafluoroethylene (PTFE)] and the further outcome.

Methods

Retrospective single-center analysis of consecutive patients treated for acute or chronic occlusion of infra-inguinal bypasses at a university hospital was conducted. Hospitalizations from 1st January 2010 through 31st December 2019 were included. Perioperative parameters from the index operation including graft material (prosthetic vs. autologous) were assessed. After bypass occlusion, the grade of ischemia, as well as the distal landing zone of the redo bypass compared with the primary bypass was investigated.

Results

In this study, 158 (65% men and 35% women with a m mean age of 70.5 years) eligible patients were included (57% vein and 42% prosthetic bypass grafts). After graft occlusion, 47% of the patients presented with symptoms of acute limb-threatening ischemia, 53% with symptoms of chronic leg ischemia. The rate of acute limb-threatening ischemia was significantly higher when prosthetic graft material was used during the index operation (p =0.016). Additionally, in case of reoperation, the landing zone of the redo bypass was significantly more distally located after occlusion of prosthetic bypass graft (p = 0.014)

Conclusion

Occlusions of prosthetic bypass grafts were associated with significantly higher rates of acute symptoms compared with vein grafts. Additionally, a shift to a more distal landing zone was recognized after the failure of a prosthetic bypass graft during the redo bypass operation.

Could prior endovascular interventions affect the results of lower extremity below the knee autologous vein bypasses?

BACKGROUND

Performing a non-selective primary endovascular approach involves risk of performing ineffective procedures and could compromise future treatments. The objective of this research is to determine if previous failed endovascular intervention could affect bypass results.

METHODS

Retrospective cohort study including 77 below the knee (BTK) bypasses with great saphenous vein (GSV) in patients with critical limb ischemia, carried out between 2008-2018. Primary bypasses (P-BP) were compared with bypasses with history of previous failed endovascular intervention (Secondary bypasses [S-BP]). Primary outcomes included: primary, primary-assisted, and secondary patency, and major amputation-free survival (AFS). The quality of GSV used was evaluated as a potential confounding factor.

RESULTS

Forty-six procedures were P-BP (59.7%) and 31 S-BP (40.3%). The mean follow-up was 35.4 (SD: 31) and 28 (DS: 30) months respectively. Univariate results showed an increased risk of loss of primary patency (HR=2.7), primary-assisted patency (HR=3.1) and secondary patency (HR=3.26) in S-BP (P<0.05). This group also presented a trend towards an increased risk of major amputation (HR=1.6; P>0.05). Suboptimal GSV was used in 29% of S-BP and 15% of P-BP. This factor was identified as confounding partially, as it decreased the influence assumed by the history of prior endovascular intervention in the analyzed variables.

CONCLUSIONS

Secondary bypasses show inferior results to primary bypasses in our series. Although the cause could be a prior failed endovascular intervention, the frequent use of suboptimal GSV in this type of patients may also contribute to this effect.

Impact of prior endovascular interventions on outcomes of lower limb bypass surgery: A systematic review and meta-analysis

The aim of this meta-analysis was to evaluate the mortality, amputation and complication rates in patients with peripheral lower limb arterial disease undergoing bypass surgery with or without a prior history of endovascular operation. A systematic literature screen was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines on four academic databases, Medline, Scopus, Embase and Cochrane Central Register of Controlled Trials. Out of 1,072 records, six articles involving 11,420 patients (mean age, 68.1±2.0 years) met the inclusion criteria. The findings presented a 2b level of evidence (i.e. overall evidence represents data from individual cohort study or low quality randomized controlled trials) and suggested lower mortality, amputation and complication rates for patients undergoing bypass surgery without any history of endovascular operation, compared with those with a history of prior endovascular operation. Moreover, a random-effect meta-analysis suggested a small, positive reduction in mortality (Hedge's g=0.08), amputation (Hedge's g=0.18) and complication rates (Hedge's g=0.05) for patients undergoing bypass surgery without any history of endovascular operation. Nevertheless, owing to the scarcity of high-quality data, further studies and randomized clinical trials are needed to confirm these effects.

Outcomes after Open Lower Extremity Revascularization in Patients with Critical Limb Ischemia

BACKGROUND

For decades, open intervention was the treatment of choice in patients requiring lower extremity revascularization. In the endovascular era, however, open and endovascular revascularization are options. The implications of prior revascularization on the outcomes for subsequent revascularization are not known. In the present study, we evaluated 30-day outcomes after open lower extremity revascularization for critical limb ischemia (CLI) in those who had previous interventions.

METHODS

The 2012-2017 open lower extremity bypass Participant User Data Files from the National Surgical Quality Improvement Program were used to identify a cohort of patients with CLI. Patients whose operation was considered emergent were excluded from the analysis. Patients were stratified on whether they had a previous open or endovascular intervention or undergoing a primary revascularization. The primary outcome measure was 30-day major adverse limb events (MALEs). Secondary outcomes included major adverse cardiac events (MACEs) and wound complications.

RESULTS

A total of 12,668 patients met study criteria with 59.6% (n = 7,549) undergoing a primary open revascularization, 22.4% (n = 2,839) having a prior endovascular intervention, and 18.0% (n = 2,280) having a prior open revascularization. There were notable differences in the baseline characteristics between the 3 groups. In addition, there were differences in the reason for intervention (rest pain versus tissue loss), type of revascularization, and type of conduit used between the 3 groups. After adjustment, a prior open revascularization was significantly associated with 30-day MALE when compared with a primary revascularization (adjusted odds ratio, 1.69; 95% confidence interval, 1.47-1.94; P < 0.001) and prior endovascular intervention (adjusted odds ratio, 1.76; 95% confidence interval, 1.46-2.12; P < 0.001). There were no differences in outcomes between primary revascularization and prior endovascular patients. There were no differences between MACEs or wound complications between the 3 groups.

CONCLUSIONS

A prior endovascular intervention does not seem to accrue any additional short-term risk when compared with primary revascularization, suggesting an endovascular-first approach may be a safe strategy in patients with CLI. However, a prior open intervention is significantly associated with 30-day MALE in patients undergoing redo open revascularization, which may be related to the rapid decline in patients once they have exhausted their best open revascularization option.

Perioperative outcomes of infrainguinal bypass surgery in patients with and without prior revascularization

OBJECTIVE

Although an increasing number of patients with peripheral arterial disease undergo multiple revascularization procedures, the effect of prior interventions on outcomes remains unclear. The purpose of this study was to evaluate perioperative outcomes of bypass surgery in patients with and those without prior ipsilateral treatment.

METHODS

Patients undergoing nonemergent infrainguinal bypass between 2011 and 2014 were identified in the National Surgical Quality Improvement Program Targeted Vascular module. After stratification by symptom status (chronic limb-threatening ischemia [CLTI] and claudication), patients undergoing primary bypass were compared with those undergoing secondary bypass. Within the secondary bypass group, further analysis compared prior bypass with prior endovascular intervention. Multivariable logistic regression analysis was used to establish the independent association between prior ipsilateral procedure and perioperative outcomes.

RESULTS

A total of 7302 patients were identified, of which 4540 (62%) underwent primary bypass (68% for CLTI), 1536 (21%) underwent secondary bypass after a previous bypass (75% for CLTI), and 1226 (17%) underwent secondary bypass after a previous endovascular intervention (72% for CLTI). Prior revascularization on the same ipsilateral arteries was associated with increased 30-day major adverse limb event in patients with CLTI (9.8% vs 7.4%; odds ratio [OR], 1.4 [95% confidence interval (CI), 1.1-1.7]) and claudication (5.2% vs 2.5%; OR, 2.1 [95% CI, 1.3-3.5]). Similarly, secondary bypass was an independent risk factor for 30-day major reintervention (CLTI: OR, 1.4 [95% CI, 1.1-1.8]; claudication: OR, 2.1 [95% CI, 1.3-3.5]), bleeding (CLTI: OR, 1.4 [95% CI, 1.2-1.6]; claudication: OR, 1.7 [95% CI, 1.3-2.4]), and unplanned reoperation (CLTI: OR, 1.2 [95% CI, 1.0-1.4]; claudication: OR, 1.6 [95% CI, 1.1-2.1]), whereas major amputation was increased in CLTI patients only (OR, 1.3 [95% CI, 1.01-1.8]). Postoperative mortality was not significantly different in patients undergoing secondary compared with primary bypass (CLTI: 1.7% vs 2.2% [P = .22]; claudication: 0.4% vs 0.6% [P = .76]). Among secondary bypass patients with CLTI, those with prior bypass had higher 30-day reintervention rates (7.8% vs 4.9%; OR, 1.5 [95% CI, 1.0-2.2]) but fewer wound infections (7.3% vs 12%; OR, 0.6 [95% CI, 0.4-0.8]) compared with patients with prior endovascular intervention.

CONCLUSIONS

Prior revascularization, in both patients with CLTI and patients with claudication, is associated with worse perioperative outcomes compared with primary bypass. Furthermore, prior endovascular intervention is associated with increased wound infections, whereas those with prior bypass had higher reintervention rates. The increasing prevalence of patients undergoing multiple interventions stresses the importance of the selection of patients for initial treatment and should be factored into subsequent revascularization options in an effort to decrease adverse events.

The association between periprocedural factors and the late outcome of percutaneous stenting of lower extremity arteries. A retrospective cohort study

Introduction

About 20–30% of the population have peripheral artery disease. Many of them require intervention, with a percutaneous procedure currently being the first choice. However, the outcomes of these interventions need regular evaluation due to continuous progress in endovascular techniques and the devices used.

Aim

The aim of this study was to analyze procedural factors influencing the outcome of endovascular intervention in patients stented for the first time due to lower extremity atherosclerosis.

Material and methods

The medical documentation of 91 patients with at least 1 year of follow-up after stenting of a lower limb artery was retrospectively evaluated. Uni- and multivariate analyses were performed.

Results

The mean observation time was 544.4 ±502.9 days. The primary patency of a stent after such a follow-up was 68.1%. Cox proportional hazard analysis revealed that the risk of target lesion revascularization was affected by the following (hazard risk, 95% confidence interval): the number of vascular segments with significant lesions (13.14, 2.28–75.8); critical limb ischemia (5.68, 1.23–26.2); localization of the target lesion in an aorto-iliac in comparison with a femoro-popliteal vascular segment (0.37, 0.14–0.7); aorto-iliac lesion class according to the TASC-II consensus (1.96, 1.1–3.8); and claudication distance (1.02, 1.01–1.03).

Conclusions

The common primary patency of a stent implanted into either an aorto-iliac or a femoro-popliteal vascular segment was similar to that found in other reports. The main factors affecting the outcome of the endovascular procedures performed were mainly related to atherosclerosis severity, not to the type of technique or device used.