Infrapopliteal Percutaneous Transluminal Angioplasty Versus Bypass Surgery as First-Line Strategies in Critical Leg Ischemia: A Propensity Score Analysis Soderstrom MI, Arvela EM, Korhonen M et al. Ann Surg 2010;252:765-73.Conclusion: Infrapopliteal percutaneous angioplasty, when feasible, can be an effective first-line strategy achieving similar long-term results as bypass surgery in patients with critical limb ischemia (CLI) when redo procedures are actively used.Summary: Retrospective studies of patient characteristics in endovascular and surgical trials often differ significantly. Propensity score analysis can be used to adjust for important differences between treatment groups. In this study, propensity score analysis was used to compare outcomes in patients who underwent percutaneous transluminal angioplasty (PTA) or bypass surgery of infrapopliteal arteries. The study cohort consisted of 1023 nonrandomized patients treated for CLI, with 262 endovascular and 761 surgical revascularization procedures performed on tibial or pedal arteries. A propensity score was used for stratification and for adjustment in multivariable analysis. Choice of treatment was based on physician preference and treatment feasibility. PTA and bypass surgery achieved similar 5-year limb salvage (75.3% vs 76.0%), similar survival (47.5% vs 43.3%), and amputationfree survival (37.7% vs 32.7%). Rates of freedom from further revascularization were also similar (73.3% vs 74.4%). Freedom from surgical revascularization was higher after bypass surgery (94.3% vs 86.2%, P Ͻ .001). Outcomes were similar with propensity-score matched pairs except for freedom from surgical revascularization, which was higher in the bypass surgery group (91.4% vs 85.3% at 5 years, P ϭ .045). In patients who underwent isolated infrapopliteal revascularization, PTA was associated with better limb salvage (75.5% vs 68.0%, P ϭ .042). Differences in freedom from surgical revascularization were not significant (78.8% vs 85.2%, P ϭ .17). The difference in the limb salvage rate was not maintained in propensity score-matched pairs (P ϭ .12).Comment: Propensity score analysis is an interesting mathematical exercise. However, as pointed out by Dr J. F. Hamming in a discussion after the article, the authors are still comparing "apples with oranges," in that endovascular treatment was reserved for patients with shorter lesions and mostly stenosis and not occlusions. The underlying problem of trying to compare treatment modalities in patients with differing extent of disease still exists. What the paper really demonstrates is that it is possible to be reasonably good at individualizing treatment in patients with CLI. The overall effectiveness of the different treatment modalities in patients with equal burden of disease is not answered by this study.

Finnvasc and modified PIII risk scoring methods predict long-term outcome of patients undergoing infrainguinal revascularization for CLI. Finnvasc score seems to perform well also in predicting immediate postoperative outcome.

When feasible, infrapopliteal PTA as a first-line strategy is expected to achieve similar long-term results to bypass surgery in CLI when redo surgery is actively utilized.

When feasible, a strategy of PTA first appears to achieve better results than infrainguinal bypass surgery in patients aged 80 years and older.

Objectives: this study was planned to evaluate the prognostic impact of end-stage renal disease (esrd) in patients with critical leg ischemia (cli) undergoing infrainguinal revascularization.Materials and Methods: 1425 patients who underwent infrainguinal revascularization for cli were the subjects of the present analysis. ninety-five patients had esrd (egFr < 15 ml/min/m 2 ), and of them 66 (70%) underwent percutaneous transluminal angioplasty and 29 (30%) underwent bypass surgery.Results: esrd patients had significantly lower overall survival (at 3-year, 27.1% vs. 59.7%, p < 0.0001), leg salvage (at 3-year, 57.7% vs. 83.0%, p<0.0001), and amputation free survival (at 3-year, 16.2% vs. 52.9%, p < 0.0001) than patients with no or less severe renal failure. the difference in survival was even greater between 86 one-to-one propensity matched pairs (at 3-year, 23.1% vs. 67.3%, p < 0.0001). esrd was an independent predictor of all-cause mortality (rr 2.46, 95%ci 1.85-3.26). logistic regression showed that age ≥ 75 years was the only independent predictor of 1-year all-cause mortality (Or 4.92, 95%ci 1.32-18.36). classification and regression tree analysis showed that age ≥ 75 years and, among younger patients, bypass surgery for leg ulcer and gangrene were associated with significantly higher 1-year mortality Conclusions: lower limb revascularization in patients with cli and end-stage renal failure is associated with favourable leg salvage. however, these patients have a very poor survival and this may jeopardize any attempt of revascularization. Further studies are needed to identify esrd patients with acceptable life expectancy and who may benefit from lower limb revascularization.