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Objective
Endovascular first approach has been widely adopted as an alternative to surgical bypass in patients who need lower extremity revascularization for diffuse femoropopliteal artery disease. The purpose of this study was to evaluate anatomical changes in extent of bypass and outcomes due to failed endovascular interventions.
Methods
We reviewed all consecutive patients treated by endovascular femoropopliteal revascularization from 2002 to 2012. Patients who required open bypass following a failed endovascular intervention were analyzed. Pre-intervention angiography was reviewed by blinded investigators with respect to anatomical characteristics and run-off scores. Location of the intended distal anastomosis was compared to the open procedure and mid-term results analyzed.
Results
566 patients underwent endovascular femoropopliteal revascularization of 665 limbs. Mean follow-up was 20 months. 123 (22%) required 171 re-interventions due to restenosis/occlusion. 30 patients required open bypass at an average of 15 months to treat failed angioplasty or stenting. The indication for revascularization was critical limb ischemia in 33% of patients at the time of the index endovascular procedure. Mean run-off score was 4.4 and included concomitant tibial intervention in 8% of those progressing to bypass. Open bypass consisted of 6 above-knee (AK), 14 below-knee (BK), and 10 tibial level interventions with vein and prosthetic used equally. The location of the distal anastomosis changed to a more distal target in 13 limbs (4 BK and 9 tibial; 43%). Mean follow up was 27 months and patency was maintained in 47% (n=14) without intervention. 5 underwent graft salvage with patch angioplasty (3) and angioplasty (2) for assisted primary patency of 63%, while 3 required redo bypass and one underwent thrombolysis for limb salvage. 7 progressed to amputation (23%).
Conclusions
When endovascular interventions on SFA lesions fail, open revascularization may be required. In our cohort, only 4.5% (30/665) of SFA interventions resulted in conversion to surgical bypass. Of these, 13 required a more distal target. In patients requiring subsequent bypass after transcatheter intervention, the patency and amputation rates were worse than historic primary bypass results. An endovascular first approach to treating claudication and CLI is safe and resulted in a low rate of progression to open bypass.