“Endovascular first” Strategies are not for Every Patient

Abstract

The term “endovascular first” was made popular by research but has gradually become accepted as a standard approach to lower limb revascularisation: “give it a go” endovascularly then bypass if this fails. This was always a misappropriation of the research data, and the meta-analysis by Hossain et al.1Hossain S. Leblanc D. Farber A. Power A. DeRose G. Duncan A. et al.Infrainguinal bypass following failed endovascular intervention compared with primary bypass: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2019; 57: 382-391Abstract Full Text Full Text PDF Scopus (9) Google Scholar shows exactly why we need to be cautious with widespread adoption of a practice without clear evidence. Endovascular first strategies were already popular when the initial results of the BASIL1 trial were reported as balloon angioplasty first is broadly similar to vein bypass first.2Adam D.J. Beard J.D. Cleveland T. Bell J. Bradbury A.W. Forbes J.F. et al.BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial.Lancet. 2005; 366: 1925-1934Abstract Full Text Full Text PDF PubMed Scopus (1610) Google Scholar Longer term, non-powered comparisons from BASIL soon showed a more subtle picture than this,3Bradbury A.W. Adam D.J. Bell J. Forbes J.F. Fowkes F.G. Gillespie I. et al.Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial.Health Technol Assess. 2010; 14 (iii-iv): 1-210Crossref Scopus (125) Google Scholar as did a wealth of other data,4Antoniou G.A. Georgiadis G.S. Antoniou S.A. Makar R.R. Smout J.D. Torella F. Bypass surgery for chronic lower limb ischaemia.Cochrane Database Syst Rev. 2017; 4: CD002000PubMed Google Scholar but the message in clinical practice had already become endovascular first in many units. By this time the enthusiasm for endovascular intervention was high, and arguing against an endovascular first approach was met with counter arguments over improved technology, better patient selection, and better medication protocols. However, if the results of this meta-analysis are to be believed, patients undergoing bypass after failed endovascular intervention fare worse than if they are offered bypass first. This is an important message because the long-term results of the BASIL trial showed that vein bypass was superior to endovascular intervention in the long term, with the caveat that it was never designed with statistical power for observations over this amount of time.3Bradbury A.W. Adam D.J. Bell J. Forbes J.F. Fowkes F.G. Gillespie I. et al.Multicentre randomised controlled trial of the clinical and cost-effectiveness of a bypass-surgery-first versus a balloon-angioplasty-first revascularisation strategy for severe limb ischaemia due to infrainguinal disease. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial.Health Technol Assess. 2010; 14 (iii-iv): 1-210Crossref Scopus (125) Google Scholar Cohort results have been more conflicted.1Hossain S. Leblanc D. Farber A. Power A. DeRose G. Duncan A. et al.Infrainguinal bypass following failed endovascular intervention compared with primary bypass: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2019; 57: 382-391Abstract Full Text Full Text PDF Scopus (9) Google Scholar These caveats affect the ability of this meta-analysis to make definitive recommendations. It predominantly includes cohort studies that will all suffer from selection bias concerning the severity of atherosclerosis, patient selection, and operator outcomes. The cohorts were generally small with low event rates, so the meta-analyses are skewed by results from the larger studies favouring primary bypass.1Hossain S. Leblanc D. Farber A. Power A. DeRose G. Duncan A. et al.Infrainguinal bypass following failed endovascular intervention compared with primary bypass: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2019; 57: 382-391Abstract Full Text Full Text PDF Scopus (9) Google Scholar In addition to this, the aforementioned counter arguments for endovascular intervention are also true in that everything has changed since many of these studies were published. Whether the mechanism by which endovascular intervention potentially affects any subsequent bypass has also changed is unknown, because that mechanism was unclear in the first place. The summary is that this analysis should strike a note of caution into our endovascular decision making. The patient with a useable vein and a more complex endovascular option needs careful consideration and counselling for the best outcomes. Editor's Choice – Infrainguinal Bypass Following Failed Endovascular Intervention Compared With Primary Bypass: A Systematic Review and Meta-AnalysisEuropean Journal of Vascular and Endovascular SurgeryVol. 57Issue 3PreviewPatients with infrainguinal peripheral arterial disease often undergo multiple revascularisation procedures. Although many centres have adopted an endovascular first approach, some are reluctant to do so for fear of compromising the outcomes of any subsequent bypasses. All studies that compared the outcomes of primary infrainguinal bypass with bypass after failed endovascular intervention were analysed. Full-Text PDF Open Archive