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Lower-extremity bypass for CLI yields better outcomes than endovascular intervention
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Lower-extremity bypass surgery predicted lower risk-adjusted major adverse limb event rates at 30 days vs. infrainguinal endovascular intervention in patients with critical limb ischemia, according to new data published in the Journal of Vascular Surgery.
According to the study, although lower-extremity bypass surgery was traditionally the preferred method of treatment for CLI, in the past 20 years, infrainguinal endovascular intervention has gained acceptance by physicians and is now more commonly used.
“Intuitively, [infrainguinal endovascular intervention] should have the advantage of lower procedural risk in the complex critical limb population with multiple medical comorbidities,” J. Hunter Mehaffey, MD, from the division of vascular and endovascular surgery and division of thoracic and cardiovascular surgery at the University of Virginia, and colleagues wrote. “However, data directly comparing [lower-extremity bypass] and [infrainguinal endovascular intervention] remain sparse. In addition, in the many studies, the heterogeneity of patients included and procedures performed along with a lack of standardization in the outcomes reported has rendered careful comparison of [lower-extremity bypass] and [infrainguinal endovascular intervention] for CLI difficult.”
In order to compare rates of major adverse limb events and MACE scores after lower-extremity bypass and infrainguinal endovascular intervention, researchers studied a propensity score-matched national cohort of patients with CLI and compared outcomes for lower-extremity bypass vs. infrainguinal endovascular intervention.
Mehaffey and colleagues used multivariate logistic regression to identify independent predictors of major adverse limb events and MACE among the cohort.
In the 3,848 cases studied, there were no differences in preoperative variables between the propensity-matched lower-extremity bypass and infrainguinal endovascular intervention groups (P > .05).
Rates of major adverse limb events were lower in the lower-extremity bypass group at 30 days (9.2% vs. 12.2%; P = .003).
On multivariate logistic regression, compared with infrainguinal endovascular intervention, bypass with single-segment saphenous vein (OR = 0.7; 95% CI, 0.54-0.92), bypass with alternative conduit (prosthetic, spliced vein or composite) vs. infrainguinal endovascular intervention (OR = 0.7; 95% CI, 0.56-0.98), antiplatelet therapy (OR = 0.8; 95% CI, 0.58-1) were protective against major adverse limb events. Statin therapy was also protective against such events (OR = 0.8; 95% CI, 0.62-0.99).
Infrageniculate intervention (OR = 1.4; 95% CI, 1.09-1.72) and a history of prior bypass of the same arterial segment (OR = 1.8; 95% CI, 1.41-2.41), were predictive of major adverse limb events.
At 30 days, researchers found that MACE rates were not significantly different (4.9% for lower-extremity bypass vs. 3.7%; P = .07) between the groups.
Age (OR = 1.02; 95% CI, 1.01-1.04), steroid use (OR = 1.8; 95% CI, 1.08-2.99), congestive HF (OR = 1.7; 95% CI, 1-1.96), beta-blocker use (OR = 1.6; 95% CI, 1.09-1.43), dialysis (OR = 2.3; 95% CI, 1.55-3.45), totally dependent functional status (OR = 3.1; 95% CI, 1.25-7.58) and suboptimal conduit for lower-extremity bypass compared with infrainguinal endovascular intervention (OR = 1.6; 95% CI, 1.08-2.36) were all independent predictors of MACE.
Although the results of this cohort show improved risk-adjusted rates of major adverse limb events at 30 days using lower-extremity bypass for the management of CLI, further study is needed, the researchers wrote. – by Dave Quaile
Disclosure s : The authors report no relevant financial disclosures.
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