Indications for a “Surgery First” Approach for the Treatment of Lower Extremity Arterial Disease

Abstract

In recent years, a tendency has developed toward an “endovascular first” approach for the treatment of or femoropopliteal arterial disease. The goal of our study was to determine which patients' long-term patency of femoropopliteal bypass (FPB) would be significant enough that they would be better served with initial primary surgical intervention. A retrospective analysis of all patients undergoing FPB from June 2006 to December 2014 was performed. Our primary endpoint was primary unassisted graft patency, defined as patent on ultrasound or angiography or a palpable pulse in the bypass on physical examination. The patients with <1 year of follow-up were excluded. We identified 241 patients who had undergone FPB on 272 limbs. The mean follow-up was 7.1 years. The FPB indication was disabling claudication in 95 limbs, critical limb ischemia (CLI) or wounds in 148 limbs, and popliteal aneurysm in 29 limbs. Of the 272 FPBs, 134 used saphenous vein grafts (SVGs), 126 used prosthetic grafts, 8 used arm vein grafts, and 4 used cadaveric or xenografts. Of the FPBs, 97 were patent for ≥5 years. Statistically significant factors for 5-year patency were use of SVG conduits (P = .01), male sex (P = .023), age <70 years (P = .003), white race (P = .014), no diabetes (P = .014), no history of chronic obstructive pulmonary disease (COPD; P = .001), and no history of cerebrovascular accident (P = .005). Grafts patent at 5 years were more likely to have been performed for claudication (5-year patency, 63.4%) or a popliteal aneurysm (73.1%) compared with critical limb ischemia or wounds (38.2%; P < .0001). The FPB conFiguration (above or below the knee, in situ vs reversed saphenous vein) was not significant for 5-year patency. SVG (P = .004), male sex (P = .034), a surgical indication of claudication or popliteal aneurysm (P < .0001), white race (P < .0001), and no history of COPD (P = .026) were statistically significant (log-rank test) for patency over time (Figs 1 and 2). Of the 272 FPBs, 23 were performed in white, non-COPD, nondiabetic, male patients without a history of cerebrovascular accident who had received SVG conduits for claudication or a popliteal aneurysm. The 5-year patency for those 23 FPBs was 91%. Young, nondiabetic, white male patients without diabetes or COPD and with an accepTable saphenous vein undergoing FPB grafting for claudication or a popliteal aneurysm are likely to have a patent FPB at 5 years and might be best served by an initial surgical procedure.Fig 2Kaplan-Meier curve for primary unassisted patency comparing men and women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)