SCVS - Perioperative and survival outcomes of surgical bypass compared with endovascular therapy for infrainguinal peripheral arterial disease and critical limb ischemia in the Vascular Quality Initiative

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Perioperative and survival outcomes of surgical bypass compared with endovascular therapy for infrainguinal peripheral arterial disease and critical limb ischemia in the Vascular Quality Initiative
Jeffrey J. Siracuse, M.D., Denis Rybin, Jeffrey A. Kalish, M.D., Mohammad Eslami, M.D., Carla C. Moreira, M.D., Robert T. Eberhardt, M.D., Naomi M. Hamburg, M.D., Alik Farber, M.D..
Boston University, Boston, MA, USA.

OBJECTIVES:
There appears to be clinical equipoise in the management of patients with critical limb ischemia (CLI) and infrainguinal peripheral arterial disease (iPAD). We analyzed patient characteristics, perioperative complications, and long term mortality for lower extremity bypass (LEB) and percutaneous vascular interventions (PVI) for CLI within the VQI.
Methods:
VQI (2010-2013) was queried for patients with CLI and iPAD treated with LEB or PVI. We evaluated all patients (cohort 1) and those without comorbidities that would discourage bypass (severe CHF, ESRD, unstable angina, positive stress test, oxygen dependence, ASA class 4/5, previous major ipsilateral amputation, and urgent/emergent case) (cohort 2). Multivariate analyses were performed to analyze length of stay (LOS), perioperative mortality, and 3-year mortality.
Results:
There were 7897 patients in cohort 1 (4838 PVI and 3059 LEB) and 4579 (2452 PVI and 2127 LEB) in cohort 2. Patients treated with PVI had higher comorbidities across both cohorts (table, * = P<.05). Most common PVI complications included hematoma (3%), access site injury (0.2%) and readmission (2.4%); most common LEB complications included wound infection (3.3%), MI (3.2%), respiratory complications (2.7%). Median LOS for PVI was lower than LEB for both cohorts (1 vs. 4 days). After adjusting for comorbidities, patients treated with PVI had lower perioperative mortality in cohort 1 (2.1% vs. 2.4%) (OR 0.59, 95% CI 0.43-0.81, P<.01), but not cohort 2 (1.4% vs. 1.3%) (OR 0.66, 0.39-1.13, P=.13). Those treated with PVI had a higher mortality at three years in both cohort 1 (30% vs. 22%) (OR 1.2, 1.1-1.4, P<.01) and 2 (26% and 16%) (OR 1.6, 1.3-2.0, P<.01).
CONCLUSIONS:
In VQI, PVI is more often offered to patients who are older and with more comorbidities. Patients offered LEB are more likely to have previous open and endovascular interventions. Patients treated with PVI had lower LOS in both cohorts and lower perioperative mortality in the full patient sample. There was no difference in perioperative mortality in lower risk patients. However, PVI had higher long-term mortality in both cohorts.
Patient characteristics
Covariate Cohort 1 PVI Chort 1 LEB Cohort 2 PVI Cohort 2 LEB
Age 71* 68* 72* 68*
Diabetes 68%* 52%* 62%* 51%*
Smoking 63%* 81%* 63% 82%*
CHF 26%* 18%* 20%* 10%*
ESRD 17%* 8%* - -
Previous bypss 6%* 14%* 6%* 14%*
Previous PTA 15%* 21%* 16%* 22%*
Tissue Loss 76%* 62%* 74%* 59%*
Ambulatory 62%* 70%* 64%* 75%*

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