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Evaluating The Impact Of Endovascular To Open Bypass Relative Surgeon Volume Ratios On Outcomes In Chronic Limb Threatening Ischemia
Andrea Alonso, MD, MSc1, Khuaten Maaneb de Macedo, MD
1, Brenda Lin, MD
1, Elizabeth King, MD
1, Jeffrey Kalish, MD
1, Alik Farber, MD, MBA
1, Karan Garg, MD
2, Allen D. Hamdan, MD
3, Mohammad Eslami, MD
4, Denis Rybin, Ph.D
1, Jeffrey J. Siracuse, MD, MBA
1.
1Boston University, Boston, MA, USA,
2NYU Langone, New York, NY, USA,
3Beth Israel Deaconess Medical Center, Boston, MA, USA,
4University of Pittsburgh Medical School, Pittsburgh, PA, USA.
OBJECTIVES:Endovascular to surgical bypass revascularization surgeon ratios for chronic limb threatening ischemia (CLTI) vary significantly in practice. Our goal was to evaluate the association of relative surgeon volume of endovascular to open bypass revascularizations with outcomes.
METHODS:The Vascular Quality Initiative (VQI) peripheral vascular intervention (PVI) and infrainguinal bypass registries were analyzed from 2019-2024. Surgeons participating in both registries were categorized in the following PVI to PVI + bypass volume percentage ratios: 0.25-0.50 (more/majority bypass), 0.51-0.75 (more PVI), 0.76-1.00 (majority PVI). Primary outcomes were rates of perioperative major ipsilateral amputations, death, and 1-year death and major amputation/death.
RESULTS:There were 18,187 patients who underwent an initial tibial revascularization procedure for CLTI (77.2% PVI and 22.8% bypass). Bypass patients were younger (68.8 vs 72.5 years, P<.001), more male (73.4% vs 57.6%, P<.001), with more currently smoking and independent ambulation preoperatively (P<.001). They had higher rates of diabetes, dialysis/transplants, congestive heart failure, abnormal stress tests, and statin use, and less aspirin use (all P<.001). On univariable analysis, majority PVI surgeons had significantly higher atherectomy usage, as compared to the other groups (P<.001). On multivariable analysis, there was no association with relative volumes and perioperative or 1-year major amputations and death(TableI). For secondary outcomes, procedure times and return to the operating room (RTOR) after a bypass were significantly impacted by relative surgeon volume ratio, with majority bypass surgeons having shorter procedure times (OR 0.88, 95% CI 10.85-0.91, P<.001) and lower reoperations (OR 0.77, 95% CI 0.64-0.94, P<.01)(TableII). There was no difference in reinterventions or technical failures following PVI(TableII).
CONCLUSIONS:Relative surgeon PVI to bypass volume ratios are not associated with overall limb and survival outcomes in tibial revascularization for CLTI. However, surgeons who perform majority bypass operations had shorter procedural times and less RTOR suggesting that higher bypass ratios in practice may achieve greater operative efficiency and reduced reoperation rates.
One year outcomes by operation type and ratio| 1-yearoutcomes | More/majoritybypass | MorePVI | MajorityPVI | P-value |
| PVI |
| Death | 74% | 80% | 81% | 0.44 |
| Amputation/death | 52% | 62% | 63% | 0.31 |
| Re-intervention/amputation/death | 72% | 70% | 72% | 0.72 |
| OpenBypass |
| Death | 86% | 86% | 87% | 0.78 |
| amputation/death | 74% | 75% | 74% | 0.77 |
| Re-intervention/amputation/death | 65% | 68% | 64% | 0.37 |
Perioperative outcomes by procedure type and ratio| Perioperativeoutcome | OR(95%CI) | P-value |
| PVI |
| Re-intervention |
| More/majoritybypassvsmajorityPVI | 1.2(0.52-2.78) | 0.89 |
| MorePVIvsmajorityPVI | 0.97(0.73-0.81) | |
| Technicalfailure |
| More/MajoritybypassvsmajorityPVI | 0.89(0.38-2.1) | 0.25 |
| MorePVIvsmajorityPVI | 0.81(0.63-1.05) | |
| Amputation |
| More/majoritybypassvsmajorityPVI | 1.17(0.64-2.12) | 0.35 |
| MorePVIvsmajorityPVI | 1.13(0.95-1.34) | |
| OpenBypass |
| ProcedureTime |
| More/majoritybypassvsmajorityPVI | 0.89(0.85-0.91) | <.001 |
| MorePVIvsmajorityPVI | 0.94(0.92-0.97) | |
| RTOR | | |
| More/majoritybypassvsmajorityPVI | 0.77(0.64-0.94) | 0.03 |
| MorePVIvsmajorityPVI | 0.86(0.71-1.03) | |
| Amputation | | |
| more/majoritybypassvsmajorityPVI | 0.94(0.51-1.74) | 0.98 |
| MorePVIvsmajorityPVI | 0.98(0.54-0.94) | |
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