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Contemporary Outcomes Of Initial Treatment Strategy Of Endovascular Intervention Versus Bypass In Patients With Critical Limb Ischemia
Eileen Lu, BA1, Khalil Qato, M.D.2, Nhan Nguyen, MPH2, Allan Conway, MD2, Guillaume Stoffels, MS3, Gary Giangola, MD2, Alfio Carroccio, MD2.
1New York Medical College, New York, NY, USA, 2Lenox Hill Hospital, New York City, NY, USA, 3NORTHWELL HEALTH-LENOX HILL HOSPITAL, New York, NY, USA.

Objective
Optimal revascularization for Critical limb ischemia (CLI) is uncertain due to the limited studies available comparing endovascular and open techniques. Our aim is to compare outcomes of endovascular and open treatment for critical limb ischemia.
Methods
This is a retrospective study looking at patients who underwent endovascular or open surgical management for CLI at our institution from 2013-2018. Patients with CLI, whose initial therapy was PVI or bypass were included. We assessed demographic, procedural and follow-up data. Specifically we looked at major adverse limb events (MALE) which included major amputation or re-vascularization as well as mortality at 30 days and one year. A multivariable Cox Proportional Hazard regression model was used to assess the relationship between Surgery group and time to MALE/Death while controlling for confounding variables.
Results
338 patients with an initial diagnosis of critical limb ischemia who underwent either bypass surgery (n=108, 32%) or endovascular intervention (n=230, 68%) were identified. The average age was 71.4, 54.4% were male, 30% were African American, 53.6% were diabetics and 93.2% had hypertension. Patients who underwent bypass were more predominantly smokers (p= 0.003), and less predominantly on dialysis at time of surgery (p = 0.01). Re-intervention rates in the bypass group, 11% were not significantly different than the PVI group (9%). In the bypass group, 20(19%) patients had a major amputation with a median time of 189.5 days compared to 23(10%) patients at a median time of 113 days in the PVI group. Mortality was 2% (median time 212.5 days) in the bypass group and 4% (median time 33.5 days) in the PVI group. Urgency of the case and CHF were significantly associated with mortality.
The cumulative incidence of MALE/death at 30 days was 4.0% in the bypass group and 3.7% in the PVI group. Incidences at one and two years are 21.1% and 48.5% in the bypass group and 19.7 and 45.9% in the PVI group, respectively. Intervention type was not found to be significantly associated with MALE/death after controlling for possible confounders (HR=0.82, p=0.43).
Conclusions
Our study suggests that an initial management strategy of bypass surgery first or PVI first do not differ in terms of limb salvage or mortality at the 30 day, 1 year and 2 year marks.


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