Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass

Abstract

Background Although open surgical bypass remains the standard revascularization strategy for patients with critical limb ischemia (CLI), many centers now perform peripheral endovascular intervention (PVI) as the first-line treatment for these patients. We sought to determine the effect of a prior ipsilateral PVI (iPVI) on the outcome of subsequent lower extremity bypass (LEB) in patients with CLI. Methods A retrospective cohort analysis of all patients undergoing infrainguinal LEB between 2003 and 2009 within hospitals comprising the Vascular Study Group of New England (VSGNE) was performed. Primary study endpoints were major amputation and graft occlusion at 1 year postoperatively. Secondary outcomes included in-hospital major adverse events (MAE), 1-year mortality, and composite 1-year major adverse limb events (MALE). Event rates were determined using life table analyses and comparisons were performed using the log-rank test. Multivariate predictors were determined using a Cox proportional hazards model with multilevel hierarchical adjustment. Results Of 1880 LEBs performed, 32% (n = 603) had a prior infrainguinal revascularization procedure (iPVI, 7%; ipsilateral bypass, 15%; contralateral PVI, 3%; contralateral bypass, 17%). Patients with prior iPVI, compared with those without a prior iPVI, were more likely to be women (32 vs 41%; P = .04), less likely to have tissue loss (52% vs 63%; P = .02), more likely to require arm vein conduit (16% vs 5%; P = .001), and more likely to be on statin (71% vs 54%; P = .01) and beta blocker therapy (92% vs 81%; P = .01) at the time of their bypass procedure. Other demographic factors were similar between these groups. Prior PVI or bypass did not alter 30-day MAE and 1-year mortality after the index bypass. In contrast, 1-year major amputation and 1-year graft occlusion rates were significantly higher in patients who had prior iPVI than those without (31% vs 20%; P = .046 and 28% vs 18%; P = .009), similar to patients who had a prior ipsilateral bypass (1 year major amputation, 29% vs 20%; P = .022; 1 year graft occlusion, 33% vs 18%; P = .001). Independent multivariate predictors of higher 1-year amputation and graft occlusion rates were prior iPVI, prior ipsilateral bypass, dialysis dependence, prosthetic conduit and distal (tibial and pedal) bypass target. Conclusions Prior iPVI is highly predictive for poor outcome in patients undergoing LEB for CLI with higher 1-year amputation and graft occlusion rates than those without prior revascularization, similar to prior ipsilateral bypass These findings provide information, which may help with the complex decisions surrounding revascularization options in patients with CLI.

Current Trends and outcomes: Endovascular Management in Arteriosclerosis Obliterans (ASO) of Lower Limb Vessels

“…[61] Thus, there is an evolving impression, endorsed by societal guidelines [62,63] that favors potential near-term benefit of PTA as the "first line approach" in specific CLI patients in comparison to open surgery. Recent data suggest more distal target anastomosis in patients who experienced tibial PTA restenosis, subsequently underwent a lower limb bypass [64] and had higher 1-year amputation and graft closure rates [65] when compared to patients without prior PTA. Likewise, the BASIL trial investigators observed worse amputation-free survival (AFS) rates in patients undergoing bypass after a failed PTA than those undergoing primary bypass [66] Long term follow up of CLI patients show high tibial PTA restenosis rates, that may require lower extremity…”

“…[67] Paclitaxel drug-eluting balloons by reducing neointimal proliferation, promote arterial patency. In prospective clinical trials In relatively small CLI patient cohorts, tibial vessel drug-eluting balloon (DEB) angioplasty significantly reduced restenosis rates and late lumen loss (LLL) at 3, 6, and 12 months [68,69] Although these angiographic assessments were not core lab adjudicated, there is a growing perception that the clinical results of DEB tibial angioplasty mirror the clinical experience in the superficial femoral artery.…”

Results of bypass graft surgery after prior angioplasty in critical limb ischaemia treatment

“…The authors concluded that BGS is a feasible approach in situations where endovascular treatments have failed. In contrast, Nolan et al [15] conducted a retrospective analysis of 603 patients with lower-limb revascularisation with a follow-up of 6 years. Previous BGS was associated with the increased use of alternative conduits, including arm veins.…”

The Increased Use of Computed Tomography Angiography and Magnetic Resonance Angiography as the Sole Imaging Modalities Prior to Infrainguinal Bypass Has Had No Effect on Outcomes

“…17e19 Interestingly, there were no differences between the 2 groups regarding prior ipsilateral bypass but more patients undergoing angiography had undergone a prior ipsilateral percutaneous intervention. Given the known worse outcomes for bypass following failed percutaneous intervention, 20 perhaps usage of CTA and MRA will increase for these patients to help improve outcomes.…”