Peroneal bypass versus endovascular peroneal intervention for critical limb ischemia

OBJECTIVE

The peroneal artery is a well-established target for bypass in patients with critical limb ischemia (CLI). The objective of this study was to evaluate the outcomes of peroneal artery revascularization in terms of wound healing and limb salvage in patients with CLI.

METHODS

Patients presenting between 2006 and 2013 with CLI (Rutherford 4-6) and isolated peroneal runoff were included in the study. They were divided into patients who underwent bypass to the peroneal artery and those who underwent endovascular peroneal artery intervention. Demographics, comorbidities, and follow-up data were recorded. Wounds were classified by Wound, Ischemia, foot Infection (WIfI) score. The primary outcome was wound healing; secondary outcomes included mortality, major amputation, and patency.

RESULTS

There were 200 limbs with peroneal bypass and 138 limbs with endovascular peroneal intervention included, with mean follow-up of 24.0 ± 26.3 and 14.5 ± 19.1 months, respectively (P = .0001). The two groups were comparable in comorbidities, with the exception of the endovascular group's having more patients with cardiac and renal disease and diabetes mellitus but fewer patients with smoking history. Based on WIfI criteria, ischemia scores were worse in bypass patients, but wound and foot infection scores were worse in endovascular patients. Perioperatively, bypass patients had higher rates of myocardial infarction (4.5% vs 0%; P = .012) and incisional complications (13.0% vs 4.4%; P = .008). At 12 months, the bypass group compared with the endovascular group had better primary patency (47.9% vs 23.4%; P = .002) and primary assisted patency (63.6% vs 42.2%; P = .003) and a trend toward better secondary patency (74.2% vs 63.5%; P = .11). There were no differences in the rate of wound healing (52.6% vs 37.7% at 1 year; P = .09) or freedom from major amputation (81.5% vs 74.7% at 1 year; P = .37). In a multivariate analysis, neuropathy was associated with improved wound healing, whereas WIfI wound score, cancer, chronic renal insufficiency, and smoking were associated with decreased wound healing. Treatment modality was not a significant predictor (P = .15).

CONCLUSIONS

Endovascular peroneal artery intervention results in poorer primary and primary assisted patency rates than surgical bypass to the peroneal artery but provides similar wound healing and limb salvage rates with a lower rate of complications. In appropriately selected patients, endovascular intervention to treat the peroneal artery is a low-risk intervention that may be sufficient to heal ischemic foot wounds.

Increasing use of open conversion for late complications after endovascular aortic aneurysm repair

OBJECTIVE

Open procedures are often required for late complications after endovascular aneurysm repair (EVAR). Our aim was to describe the indications for open interventions and their postoperative outcomes and to specifically examine our experience with limited conversions in which problem endoleaks are targeted without endograft explantation.

METHODS

We reviewed patients from 2002 to 2017 who underwent any surgical abdominal aortic operation after a previous EVAR. Baseline characteristics, preoperative imaging, procedural details, and postoperative outcomes were reviewed. The primary end point was 30-day mortality.

RESULTS

There were 102 patients who underwent open conversion 3.8 ± 3.1 years after EVAR. The numbers increased significantly in recent years, with 18 cases performed in 2016; 48.5% of patients had undergone 1.9 ± 1.0 prior endovascular interventions. The indication for surgical conversion was an endoleak in 85 patients and infection in 15. One patient had a limb occlusion and another a proximal aneurysm. The 30-day mortality was 6.2% in 65 patients treated electively for endoleak but higher in 20 ruptures (40.0%) and 15 infections (40.0%). In a multivariate logistic regression model, independent predictors of 30-day mortality were rupture (odds ratio [OR], 6.70; 95% confidence interval [CI], 1.75-25.60; P = .005), endograft infection (OR, 8.48; 95% CI, 1.99-36.20; P = .004), and use of a supraceliac clamp (OR, 4.80; 95% CI, 1.47-15.66; P = .009). Transient acute kidney injury (12.8%) and prolonged intubation (11.8%) were the most common postoperative complications. In 65 patients treated for endoleak without rupture, 37 underwent endograft explantation, whereas 28 had a graft-preserving intervention (branch vessel ligation for type II endoleak in 26, external banding of the aneurysm neck for type IA endoleak in 8). Mortality was 8.1% when the endograft was explanted and 3.6% when it was not (P = .63). During 3.0 ± 3.5 years of follow-up, there was one reintervention after endograft explantation (for rupture secondary to type IB endoleak) and two reinterventions after graft preservation (for a new type IA endoleak and a new type II endoleak). Survival was 87.4% at 1 year and 70.9% at 5 years.

CONCLUSIONS

Open conversion is playing an increasing role in the management of late EVAR complications. Endoleaks treated electively by open conversion are reasonably safe and show good midterm durability, even with graft-preserving interventions that avoid endograft explantation.