Abstract
We aimed to compare the clinical outcomes between endovascular treatment and inframalleolar bypass surgery for critical limb ischemia (CLI) in patients with thromboangiitis obliterans (TAO) and to assess the role of bypass surgery in the era of innovative endovascular treatment. Between January 2007 and December 2017, a total of 33 consecutive patients with the diagnosis of TAO presenting with CLI who underwent endovascular treatment (endovascular group, n = 22) or bypass surgery to the pedal or plantar vessels (bypass group, n = 11) were included and analyzed retrospectively. The primary endpoint was defined as a major amputation of the index limb, and the secondary endpoint was defined as graft occlusion, regardless of the number of subsequent procedures. In the bypass group, six patients (55%) had undergone previous failed endovascular procedures and/or arterial bypass surgery to the index limb before inframalleolar bypass, and two patients (18%) received microvascular flap reconstruction after bypass surgery. During the median follow-up period of 32 months (range 1–115 months), there were no significant differences in primary and secondary endpoints between the two groups although the bypass group had a higher Rutherford class than the endovascular group. Kaplan–Meier survival analysis showed that there were similar limb salvage (P = 0.95) and graft patency rates (P = 0.39). In conclusion, endovascular treatment is a valid strategy leading to an acceptable limb salvage rate for TAO patients, and surgical bypass to distal target vessels could play a vital role in cases of previous failed endovascular treatment or extensive soft tissue loss of the foot.
Highlights
Our management strategy for thromboangiitis obliterans (TAO) is determined based on symptoms and signs of limb ischemia (Rutherford class) [10]; conservative treatment including cessation of smoking, possible use of antiplatelet or vasodilator therapy, and local wound care, is recommended as the first line treatment in patients without critical limb ischemia (CLI) (Rutherford class 1–3) whereas endovascular treatment with conservative treatment is recommended in selected patients with CLI or whose local symptoms do not improve after conservative treatment
Of the 177 consecutive patients with the diagnosis of TAO, 33 patients presenting with CLI who underwent an endovascular procedure (n = 22, 67%) or bypass surgery (n = 11, 33%) were included in the analysis; we excluded 144 patients not indicated for endovascular or surgical treatment
Based on our review of the patient outcomes under our management strategy, we found that the results of endovascular treatment and distal bypass surgery were comparable, and no difference in the limb salvage and secondary graft patency rates was noted even though most inframalleolar bypass surgeries were carried out in cases with a higher Rutherford class or after a previous failed endovascular procedure and/or arterial bypass surgery
Summary
Between January 2007 and December 2017, of the 177 consecutive patients with the diagnosis of TAO, 33 patients (18.6%) presenting with CLI (Rutherford class 4–6) who underwent endovascular treatment or bypass surgery to the pedal or plantar arteries or veins were included in the study [10,11]. Of the 177 consecutive patients with the diagnosis of TAO, 33 patients presenting with CLI who underwent an endovascular procedure (n = 22, 67%) or bypass surgery (n = 11, 33%) were included in the analysis; we excluded 144 patients not indicated for endovascular or surgical treatment.
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