Long-Term Durability of Infrainguinal Endovascular and Open Revascularization for Disabling Claudication

Abstract

Long-term outcomes after revascularization for disabling claudication (DC) are still unknown. We compared clinical outcomes and long-term durability of infrainguinal endovascular intervention (EVI) and open intervention for DC. Patients with DC who had open intervention (n = 93) or EVI (n = 171) between June 2001 and December 2013 were grouped as open-great saphenous vein (GSV; n = 23), open-polytetrafluoroethylene (PTFE; n = 36), open-femoral endarterectomy (FEA; n = 34), EV-A/B (n = 29), and EV-C/D (n = 51). Patency, sustained clinical success (improvement of symptoms, no target extremity revascularization, no amputation), secondary clinical success (sustained clinical success with target extremity revascularization), and major adverse limb event- and major adverse cardiovascular event-free survival were compared. Mean follow-up was 58 ± 39 (0-161) months. Primary patency was best in FEA and EV-A/B groups, but assisted primary patency and secondary patency were similar in open-GSV, EV-A/B, and FEA groups, which were significantly better than in open-PTFE and EV-C/D groups. Major adverse limb event-free survival was best in the FEA group and similar in others. Ipsilateral amputation rate of the whole cohort was 1.9% (22, 32, 69, 94, and 100 months). Overall major adverse cardiovascular event-free survival and overall survival at 5 years were 62% ± 3% and 72% ± 3% with no difference between groups. Sustained clinical success was best in FEA, less but similar in EV-AB and open-GSV, and worst in open-PTFE and EV-CD groups. Secondary clinical success was similar in open-GSV, EV-A/B, and FEA groups and significantly better than in open-PTFE and EV-C/D groups (Table). In open-GSV and EV-A/B groups, 70% to 81% remained asymptomatic, 17% to 21% presented with recurrent claudication, and 8% to 4% had limb-threatening ischemia; 26% to 24% had EVI ± open reinterventions, 13% to 11% being a bypass. In last follow-up, 96% to 100% remained asymptomatic, with no amputations. In open-PTFE and EV-C/D groups, 44% to 45% remained asymptomatic, 36% to 55% presented with recurrent claudication, 19% to 10% had limb-threatening ischemia, and 39% to 41% had EVI ± open reinterventions, 19% to 16% being a repeated bypass. In last follow-up, 64% to 78% remained asymptomatic and 25% to 9% mildly symptomatic. The durability of FEA is excellent for claudication. Excellent long-term outcomes can be achieved in EV-A/B or GSV bypass, with not insignificant (25%) reintervention rates. For EV-C/D and PTFE bypass, significantly more reinterventions are needed (40%), achieving acceptable long-term outcomes. Patients need to be fully informed of these expected outcomes, particularly reintervention rates, and GSV bypass should be preferred to PTFE or EVI in patients undergoing revascularization for TransAtlantic Inter-Society Consensus C/D disease, when feasible.TableKaplan-Meier patency, freedom from major adverse limb event (MALE) and major adverse cardiovascular event (MACE), and clinical success rates5-yearOpen bypass GSV, % (n = 23)Open bypass PTFE, % (n = 36)EV-A/B, % (n = 62)EV-C/D, % (n = 109)FEA ± EIA stent, % (n = 34)P valuePrimary patency58 ± 1346 ± 972 ± 838 ± 696 ± 4<.001Assisted primary patency85 ± 851 ± 987 ± 651 ± 696 ± 4<.001Secondary patency89 ± 756 ± 996 ± 361 ± 696 ± 4<.001Freedom from MALE73 ± 1370 ± 877 ± 870 ± 597 ± 3.015Freedom from MACE52 ± 1363 ± 861 ± 764 ± 564 ± 10.996Overall survival61 ± 1269 ± 867 ± 776 ± 581 ± 7.783Sustained clinical success58 ± 1346 ± 961 ± 938 ± 689 ± 6<.001Secondary clinical success89 ± 756 ± 996 ± 361 ± 696 ± 4<.001EIA, External iliac artery; FEA, femoral endarterectomy; GSV, great saphenous vein; PTFE, polytetrafluoroethylene. Open table in a new tab