Impact Of Antithrombotic Strategies On Femoropopliteal Bypass Graft Outcome
Young Kim, MD, MS, Charles DeCarlo, MD, Shiv S. Patel, Sujin Lee, MD, Imani E. McElroy, MD, Monica Majumdar, MD, Abhisekh Mohapatra, MD, Anahita Dua, MD, MS, MBA.
Massachusetts General Hospital, Boston, MA, USA.
OBJECTIVES: Anticoagulant and antiplatelet (AC/AP) medications have been reported to improve bypass graft patency, however, the optimal AC/AP strategy remains unclear in the heterogenous peripheral artery disease population.
METHODS: A multi-institutional retrospective review utilizing the Research Patient Data Registry (RPDR) database from 1995- 2020 was performed for all patients who underwent femoropopliteal bypass procedures (identified via CPT codes). Electronic medical records were used to obtain demographic information, comorbidities, smoking status, operative details (bypass target), postoperative AC/AP medications, postoperative complications, and long-term outcomes were reviewed for the cohort. Cox proportional hazards model was used to determine independent risk factors for major adverse limb events (MALE) following bypass. MALE was defined as reintervention for patency or major amputation of index limb (above- or below-knee amputation). Median follow-up period was two years.
RESULTS: A total of 1421 patients underwent femoropopliteal bypass between 1995-2020 throughout five institutions included in this study. Complete data was available for 1292/1421 (90.9%) patients. Indications for bypass included intermittent claudication (21.4%), rest pain (30.3%), tissue loss (33.5%), and non-atherosclerotic disease (14.8%). Distal bypass targets comprised above-knee (38.6%) and below-knee (61.4%) popliteal arteries. Patients were divided into six groups based on postoperative AC/AP use including none (n=57, 4.4%), mono-antiplatelet therapy (MAPT) (n=587, 45.4%), dual antiplatelet therapy (DAPT) (n=214, 16.6%), AC alone (n=73, 5.7%), AC+MAPT (n=319, 24.7%), and AC+DAPT (n=42, 3.3%). Postoperative bleeding complications were low for both hematoma (3.7%) and pseudoaneurysm (0.7%). There was no difference in bleeding complications across AC/AP groups. After adjusting for patient factors, below-knee bypass target (HR 1.25 [1.04-1.52], p=0.019) and bypass for tissue loss (HR 1.40 [1.04-1.88], p=0.028) were independent predictors for MALE. Great saphenous vein conduit trended towards protection for MALE, compared with prosthetic grafts (HR 0.84 [0.70-1.01], p=0.06). No AC/AP regimen was predictive of MALE, even within the sub-group analysis of above-knee and below-knee bypass cohorts.
CONCLUSIONS: Among patients undergoing femoropopliteal bypass grafting, no combination of anticoagulation or antiplatelet medications was protective of graft patency, however, a below-knee target and tissue loss were associated with MALE. Medication regimen may be individualized post-bypass with regard to other concomitant medical comorbidities.
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