Superior Short- and Long-Term Cardiovascular Morbidity and Mortality in Patients Undergoing PTFE Tibial/Peroneal Arterial Revascularization Compared to Primary Amputation
Nicholas J. Gargiulo, III, MD FACS RPVI RVT RDMS1, Frank J. Veith, MD FACS2, David J. O'Connor, MD FACS RPVI RVT3.
1The Brookdale University Hospital and Medical Center, New York, NY, USA, 2NYU and The Cleveland Clinic, New York, NY, USA, 3Hackensack Medical Center at UMDNJ, Hackensack, NJ, USA.
OBJECTIVES: Polytetrafluoroethylene (PTFE) tibial and peroneal bypasses without vein cuffs, patches or arteriovenous fistulas have been advocated for critical limb ischemia. We hypothesize superior short (30 day) and long-term (1-5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation. METHODS: A retrospective analysis was performed on a cohort of 23,391 patients with critical limb ischemia requiring revascularization between July 1977 and January 2017. In this cohort, 443 (1.89%) of the 23,391 patients underwent 443 PTFE bypasses to a tibial or peroneal artery without any adjunctive procedure. In this same cohort, 103 (0.44%) patients had no distal target vessel for revascularization despite thrombolytic and/or anticoagulation/anti-platelet therapy and required primary amputation. Short (30 day) and long-term (1 -5 years) cardiovascular morbidity and mortality were compared between the PTFE and primary amputation group. In addition, ethnic background, TASC distribution, hemoglobin A1C levels, and inflammatory mediators (CRP, IL-6, and IL-10) were compared. RESULTS: Short term (30 day) cardiovascular outcome in the PTFE (0.3%, 0.5%, 0%) cohort far exceeded that in the primary amputation (3%, 7%, 21%) group with regards to stroke, MI and death. In addition re-admission rates for the PTFE (13%) group was statistically less than the primary amputation (21%) cohort. These short term cardiovascular benefits were also observed long term both at 1 and 5 years in the PTFE (0.7%, 1.1%, 9%) cohort as compared to the primary amputation (5%, 13%, 17%) cohort. Interestingly, the primary amputation cohort manifested a greater distribution of TASC II D atherosclerotic disease and a greater percentage of Latino patients compared to the PTFE cohort. There was no direct correlation between hemoglobin A1C level, PTFE patency or successful limb salvage rates in the two cohorts (P>0.02). CONCLUSIONS: We have observed a superior short (30 day) and long-term (1-5 years) cardiovascular morbidity and mortality in those patients undergoing PTFE grafting as compared to those undergoing primary amputation.
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