Open Bypass Is Superior to Endovascular Revascularization in Patients Undergoing Reintervention for Chronic Limb-threatening Ischemia Using a Medicare-linked Database

Abstract

The need for reinterventions following lower extremity revascularization (LER) is common, ranging from 13% to 85% depending on different follow-up periods. Prior literature has detailed the outcomes of bypass therapy (BT) and endovascular therapy (ET) for initial LER for chronic limb-threatening ischemia. Nonetheless, there is a paucity of data regarding the best revascularization technique for patients undergoing reintervention following prior revascularization. This study aims to describe the outcomes of BT vs ET in patients with prior open or endovascular LER. We identified all patients with a history of prior ipsilateral LER who had undergone redo LER for chronic limb-threatening ischemia from 2010 to 2019 in the Vascular Quality Initiative VISION database. Patients who had undergone suprainguinal procedures were excluded. Study groups included BT vs ET in patients with prior ET and BT vs ET in patients with prior BT. A total of 17,145 patients had undergone prior ET with 69.7% undergoing redo ET and 30.3% undergoing BT, and 15,905 patients had undergone prior BT with 83.7% undergoing ET and 16.3% undergoing redo BT. Among patients with prior ET, patients undergoing BT were more likely to be smokers (79% vs 67.1%; P < .001), present with rest pain (38.8% vs 27%; P < .001), and lower ankle-brachial index (ABI) (0.6 ± 0.6 vs 0.8 ± 0.6; P < .001). BT was associated with a lower risk of 1-year major amputation/death (adjusted hazard ratio [aHR], 0.75; 95% confidence interval [CI], 0.7-0.8; P < .001), ACM (aHR, 0.8; 95% CI, 0.7-0.9; P < .001), major amputation (aHR, 0.7; 95% CI, 0.6-0.8; P < .001), and revascularization (aHR, 0.76; 95% CI, 0.7-0.9; P < .001). Among patients with prior BT, redo BT patients were more likely to be smokers (86.2% vs 67.7%; P < .001), present with rest pain (46.7% vs 27.8%; P < .001), and have a lower ABI (0.5 ± 0.5 vs 0.8 ± 0.6; P < .001). Redo BT was associated with improved 1-year major amputation/death (aHR, 0.8; 95% CI, 0.7-0.9; P < .001), ACM (aHR, 0.7; 95% CI, 0.67-0.8; P < .001), major amputation (aHR, 0.8; 95% CI, 0.7-0.9; P = .008), and revascularization (aHR, 0.76; 95% CI, 0.7-0.8; P < .001). These results persisted at 5 years (Table, Figure). The present study shows that revascularization with ET is performed more frequently in patients with prior BT or ET. Despite a higher percentage of smoking, rest pain, and lower ABI in patients undergoing redo BT, BT had better outcomes with improved limb salvage, durability, AFS and ACM (all-cause mortality) compared with redo ET. Future prospective studies are needed to confirm our findings.TableLog-rank test and multivariable Cox regression analysis of 5-year outcomesETBTLog-rankBT vs ETP valueSurvival function (%)Survival function (%)HR (95% CI)Prior PVI Amputation or deatha74.361.5<0.0010.77 (0.7-0.8)<.001 Mortalityb66.451.4<0.0010.78 (0.7-0.8)<.001 Major amputationc25.219.2<0.0010.7 (0.6-0.8)<.001 Revascularizationd6351<0.0010.7 (0.7-0.8)<.001Prior bypass Amputation or deathe74.262.9<0.0010.8 (0.78-0.9)<.001 Mortalityf65.951.2<0.0010.79 (0.7-0.9)<.001 Major amputationg25.223.40.0010.87 (0.78-0.97).013 Revascularizationh63.250.5<0.0010.7 (0.7-0.8)<.001BT, Bypass therapy; CI, confidence interval; ET, endovascular therapy; PVI, peripheral vascular intervention.a Adjusting for age, gender, history of congestive heart failure (CHF), coronary artery disease (CAD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), preoperative aspirin, preoperative P2Y12 antagonist, preoperative statins, preoperative angiotensin-converting enzyme inhibitors (ACEIs), presenting with rest pain, and below knee intervention.b Adjusting for age, gender, history of CHF, CAD, CKD, COPD, preoperative aspirin, preoperative P2Y12 antagonist, preoperative statins, preoperative ACEIs, and presenting with rest pain.c Adjusting for age, race, history of CHF, CKD, diabetes, preoperative ACEIs, presenting with rest pain, and below-knee intervention.d Adjusting for age, gender, smoking, CKD, preoperative P2Y12 antagonist, presenting with rest pain, and below-knee intervention.e Adjusting for age, gender, race, history of CHF, CAD, CKD, preoperative aspirin, preoperative P2Y12 antagonist, preoperative statins, presenting with rest pain, and below-knee intervention.f Adjusting for age, gender, history of CHF, CAD, CKD, COPD, preoperative aspirin, preoperative P2Y12 antagonist, preoperative statins, preoperative ACEIs, and presenting with rest pain.g Adjusting for age, race, history of CHF, CKD, CAD, preoperative ACEIs, presenting with rest pain, and below-knee intervention.hAdjusting for age, gender, smoking, CKD, preoperative P2Y12 antagonist, presenting with rest pain, preoperative aspirin, preoperative ACEI, preoperative P2Y12 antagonists, and below-knee intervention. Open table in a new tab