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Bypass Yielded Higher Reintervention Rates than Stenting in PAD
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Femoral-popliteal bypass was associated with a significantly higher reintervention rate than stenting in a cohort of individuals with peripheral arterial disease.
The aim of the study was to compare two strategies in patients with symptomatic PAD: femoral-popliteal bypass vs. angioplasty and stenting.
Eligible participants included 1,237 individuals with a presumptive diagnosis of PAD at Johns Hopkins Bayview Medical Center during September 2005 to September 2010. Symptomatic patients who failed percutaneous transluminal angioplasty or stenting of the superficial femoral artery or femoral-popliteal artery were selected.
Outcome measures included patency and reintervention rates in the two main groups. Patency within the TransAtlantic Inter-Society Consensus (TASC) II subgroup also was evaluated.
The analysis included 104 symptomatic patients, 61 of whom were men.
Angioplasty and stenting were performed in 77% of patients with TASC II A and B lesions. Seventy-three percent of those in the TASC C and D group underwent bypass (P<.01).
Patients in the stent group demonstrated improved primary patency compared with the bypass group at 24 months (67% vs. 49%; P=.05).
Reintervention rates at 2 years were 31% in the stent group and 54% in the bypass group (P=.02).
A reduced hazard of patency failure occurred in patients with TASC A and B lesions vs. those with TASC C and D lesions (HR=2.42; 95% CI, 1.26-4.65; P<.01).
“This is the first study that documents higher reintervention rates for femoral-popliteal bypass compared with angioplasty and stenting,” the researchers concluded, noting that an increased incidence of advanced disease in the bypass group may be the reason. “This emphasizes that one must consider the patient population undergoing intervention when comparing revascularization procedures.”
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Robert Yeh, MD
In this study, Malas and colleagues have examined outcomes of patients undergoing endovascular and open surgical bypass of lower extremity PAD at a single center. Their findings, that physicians preferentially treat less severe disease using endovascular approaches while reserving surgery for cases of more severe atherosclerosis, are in accordance with the current guidelines for lower extremity revascularization and underscore the importance that both procedures have a place in the therapeutic arsenal to treat severe PAD. A critical take away from their work is that observational studies are often not well suited to compare treatment alternatives, particularly when patient characteristics strongly influence the choice of procedure undertaken. The authors' conclusion that “one must consider the patient population undergoing intervention when comparing revascularization procedures” is true not only for this comparison, but also for others including the comparisons of carotid stenting with carotid endarterectomy, and PCI with CABG.
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