Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

• Published in: Journal of vascular surgery 2017-10, Vol.66 (4), p.1109-1116.e1
• Main Authors: Mehaffey, J. Hunter, Hawkins, Robert B., Fashandi, Anna, Cherry, Kenneth J., Kern, John A., Kron, Irving L., Upchurch, Gilbert R., Robinson, William P.
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Blood Vessel Prosthesis Implantation - adverse effects; Chi-Square Distribution; Critical Illness; Databases, Factual; Endovascular Procedures - adverse effects; Female; Heart Diseases - diagnosis; Heart Diseases - etiology; Heart Diseases - prevention & control; Humans; Ischemia - complications; Ischemia - diagnosis; Ischemia - physiopathology; Ischemia - surgery; Logistic Models; Lower Extremity - blood supply; Male; Middle Aged; Multivariate Analysis; Odds Ratio; Peripheral Arterial Disease - complications; Peripheral Arterial Disease - diagnosis; Peripheral Arterial Disease - physiopathology; Peripheral Arterial Disease - surgery; Propensity Score; Protective Factors; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2017.04.036

Lower extremity bypass (LEB) has traditionally been the “gold standard” in the treatment of critical limb ischemia (CLI). Infrainguinal endovascular intervention (IEI) has become more commonly performed than LEB, but comparative outcomes are limited. We sought to compare rates of major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) after LEB and IEI in a propensity score-matched, national cohort of patients with CLI. The National Surgical Quality Improvement Program (NSQIP) vascular targeted files (2011-2014) for LEB and IEI were merged. CLI patients were identified by ischemic rest pain or tissue loss. Patients were matched on a 1:1 basis for propensity to undergo LEB or IEI. Primary outcomes were 30-day MALEs and MACEs. Within the propensity-matched cohort, multivariate logistic regression was used to identify independent predictors of MALEs and MACEs. A total of 13,294 LEBs and IEIs were identified, with 8066 cases performed for CLI. Propensity matching identified 3848 cases (1924 per group). There were no differences in preoperative variables between the propensity-matched LEB and IEI groups (all P > .05). At 30 days, rates of MALEs were significantly lower in the LEB group (9.2% LEB vs IEI 12.2%; P = .003). On multivariate logistic regression, bypass with single-segment saphenous vein vs IEI (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.54-0.92; P = .01), bypass with alternative conduit (prosthetic, spliced vein, or composite) vs IEI (OR, 0.7; 95% CI, 0.56-0.98; P = .04), antiplatelet therapy (OR, 0.8; 95% CI, 0.58-1.00; P = .049), and statin therapy (OR, 0.8; 95% CI, 0.62-0.99; P = .04) were protective against MALEs, whereas infrageniculate intervention (OR, 1.4; 95% CI, 1.09-1.72; P = .01) and a history of prior bypass of the same arterial segment (OR, 1.8; 95% CI, 1.41-2.41; P