Outcomes of bypass versus endovascular procedures in long chronic total occlusions of the superficial femoral artery – a 10-year cohort study
DOI:
https://doi.org/10.48750/acv.669Keywords:
femoropopliteal disease, chronic total occlusion, superficial femoral artery, bypass surgery, endovascular treatment, peripheral artery diseaseAbstract
BACKGROUND: With the development of advanced endovascular technologies to treat chronic total occlusions of the superficial femoral artery (SFA-CTO), endovascular procedures have become more common, with supragenicular femoropopliteal artery bypasses reserved for a subset of patients. We aim to compare outcomes of long SFA-CTOs treated with surgical bypass versus endovascular procedures.
METHODS: Single-centre retrospective cohort study in a tertiary centre including all patients with SFA-CTOs (femoropopliteal GLASS grade 4/TASC-II D) submitted to a supragenicular femoropopliteal artery bypass (OR group) or endovascular revascularisation procedure (EVT group) from February 2015 to January 2025. Patients undergoing revascularisation of other anatomical sectors were excluded. Baseline characteristics, peri-procedural and follow-up data were obtained. The primary endpoint is major adverse limb events (MALE). The secondary endpoints are MALE-free survival, reintervention rates, amputation rates, and mortality rates.
RESULTS: 119 patients were included (71 in the OR group vs. 48 in the EVT group). Eighty-six per cent (N=61N=61) of the OR group received a prosthetic conduit. Median age was 68 years (IQR 63-74), and 75 patients (63%63%) had chronic limb-threatening ischemia. The median hospital stay was shorter in the EVT group (2 vs. 9 days; p<.001p<.001). Other characteristics, such as age, risk factors, and Leriche-Fontaine classification, did not differ between groups. During a median follow-up period of 51 months (IQR 26-78), MALE were higher in the OR group (44%44%) vs. 25%25% - p=.038p=.038) despite no significant differences in MALE-free survival. A higher rate of reintervention was also found in the OR group (39%39% vs. 21%21% p=.033p=.033). There were no significant differences in amputation or mortality rates between groups.
CONCLUSION: Patients with long SFA-CTOs had similar rates of limb salvage and mortality after bypass or endovascular interventions. Despite similar comorbidity burdens in both groups, MALE and reintervention rates were higher after bypass, suggesting an endovascular-first approach.
Downloads
References
Varghese V, Virk HUH, Lakheter V, Tabaza L, Oni E, Marreddy R, et al. Femoral Artery Chronic Total Occlusion Revascularization (FACTOR) score and Algorithm: Feasibility and Validation in a Single-Center Study of Femoropopliteal Occlusions. J Invasive Cardiol. 2020;32:E338-48.
Norgren L, Hiatt WR, Dormandy JA, Nehler, Harris KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45:S5-67.
Guo X, Xue G, Huang X, Xie H, Liang W, Zhang J, et al. Outcomes of endovascular treatment for patients with TASC II D femoropopliteal occlusive disease: a single center study. BMC Cardiovasc Disord. 2015;15:44.
Zlatanovic P, Mahmoud AA, Cinara I, Cvetic V, Lukic B, Davidovic L. Comparison of Long-Term Outcomes After Endovascular Treatment Versus Bypass Surgery in Chronic Limb Threatening Ischaemia Patients with Long Femoropopliteal Lesions. Eur J Vasc Endovasc Surg. 2020;61:258-69.
Dosluoglu HH, Cherr GS, Lall P, Harris LM, Dryjski ML. Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease. J Vasc Surg. 2008;48:1166-74.
Korhonen M, Biancari F, Soderstrom M, Arvela E, Halmesmaki K, Albäck A, et al. Femoropopliteal Balloon Angioplasty vs. Bypass Surgery for CLI: A Propensity Score Analysis. Eur J Vasc Endovasc Surg. 2010;41:378-84.
Antoniou GA, Chalmers N, Georgiadis GS, Lazarides MK, Antoniou SA, Serracino-Inglott F, et al. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg. 2012;57:242-53.
Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg. 2019;58:S1-S109.
Veraldi GF, Mezzetto L, Macri M, Criscenti P, Corvasce A, Poli R. Comparison of endovascular versus bypass surgery in femoropopliteal TASC II D lesions: a Single-Center Study. Ann Vasc Surg. 2017;47:179-87.
Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. The Lancet. 2005;366:1925-34.
Bradbury AW, Moakes CA, Popplewell M, Meecham L, Bate GR, Kelly L, et al. A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2): an open-label, randomised, multicentre, phase 3 trial. The Lancet. 2023;401:1798-809.
