Failed Prior Endovascular Intervention Do Not Affect Outcomes of Infra-Inguinal Bypasses for Critical Limb Ischemia
Kyongjune B. Lee, MD, Alexander Yang, BS, Anton Sidawy, MD, MPH, Richard Amdur, PhD, Robyn Macsata, MD, Bao-Ngoc Nguyen, MD.
The George Washington University Hospital, Washington, DC, USA.
OBJECTIVE:
Failed prior endovascular intervention could adversely affect the outcomes of subsequent infra-inguinal bypasses in the corresponding limb but this perception is not well supported in the literature due to conflicting data. This study addresses this controversial issue via analysis of a multicenter prospectively collected database.
METHODS:
Patients who underwent infra-inguinal bypass for critical limb ischemia were identified in the targeted ACS-NSQIP database from 2005 to 2015. These patients were stratified into four groups: first time femoral-popliteal bypass (FemPop), femoral-popliteal bypass after failed endovascular revascularization (Endo-FemPop), first time femoral-tibial bypass (FemTib), and femoral-tibial bypass after failed endovascular revascularization (Endo-FemTib). Thirty-day outcomes including mortality, graft patency, major amputations and major organ dysfunction were measured. Multivariate logistic regression model was used for data analysis; power was 80% to detect a difference in incidence of 1.25% for FemPop and 1.9% for FemTib.
RESULTS:
We identified 6720 patients who underwent surgery for critical limb ischemia: 3743 FemPop, 944 Endo-FemPop, 1559 Fem-Tib, and 474 Endo-FemTib. Patients were mostly matched among four groups except for minor differences in sex, hypertension, and pre-operative renal function. As the table shows, paired comparison between FemPop and Endo-FemPop revealed no significant differences in 30-day mortality, loss of patency, major amputation, or major organ dysfunction. However, Endo-FemPop significantly required more transfusion than FemPop. Similarly, there were no significant differences in 30-day outcomes between FemTib and Endo-FemTib in mortality, graft patency, amputation, and other major organ dysfunction. Endo-FemTib also had significantly higher transfusion rate than FemTib (Table).
CONCLUSION:
Failed prior endovascular intervention generally does not adversely affect 30-day outcomes of infra-inguinal bypasses. Increase in transfusion requirements in bypass after failed endovascular intervention is likely related to increased surgical complexity. More data on long-term follow up is needed.
Table: 30-day Outcomes of Infra-Inguinal Bypass After Failed Endovascular Revascularization
| Outcomes | FemPop (n=3743) | Endo-FemPop (n=944) | OR | p |
| Mortality | 41 (1.1%) | 7 (0.7%) | 0.64 (0.29 - 1.45) | 0.34 |
| Cardiac* | 95 (2.5%) | 28 (3%) | 1.14 (0.74 - 1.76) | 0.55 |
| Pulmonary** | 82 (2.2%) | 16 (1.7%) | 0.68 (0.39 -1.17) | 0.16 |
| Renal Dysfunction | 31 (0.8%) | 7 (0.7%) | 0.81 (0.35 - 1.85) | 0.61 |
| Amputation | 68 (2.3%) | 15 (2.0%) | 0.84 (0.48 - 1.49) | 0.56 |
| Loss of Patency | 45 (1.2%) | 16 (1.7%) | 1.54 (0.86 - 2.75) | 0.14 |
| Transfusion | 642 (17.2%) | 212 (22.5%) | 1.39 (1.14 - 1.71) | <0.01 |
| Outcomes | FemTib (n=1559) | Endo-FemTib (n=474) | OR | p |
| Mortality | 24 (1.5%) | 5 (1.1%) | 0.76 (0.28 - 2.03) | 0.58 |
| Cardiac* | 64 (4.1%) | 23 (4.9%) | 1.36 (0.82 - 2.25) | 0.23 |
| Pulmonary** | 50 (3.2%) | 16 (3.4%) | 1.16 (0.65 - 2.08) | 0.62 |
| Renal Dysfunction | 24 (1.5%) | 4 (0.8%) | 0.54 (0.18 - 1.57) | 0.25 |
| Amputation | 55 (4.5%) | 15 (4%) | 0.94 (0.52 - 1.70) | 0.84 |
| Loss of Patency | 40 (2.6%) | 9 (1.9%) | 0.67 (0.32 - 1.41) | 0.29 |
| Transfusion | 438 (28.9%) | 174 (36.7%) | 1.42 (1.13 - 1.79) | <0.01 |
*Cardiac = MI, cardiac arrest
**Pulmonary = Pneumonia, Reintubation, prolonged ventilation > 48 hours
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