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Infrapopliteal Revascularization For Chronic Limb Threatening Ischemia: Comparison Of Autologous Vein Bypass Vs Endovascular Intervention As Initial Revascularization
Isaac H. Naazie, MD, Mariel Rivero, MD, Sikandar Khan, MBBS, Brittany H. Montross, MD, Helen Potter, MD, Quratulain Khan, MBBS, Nader Nader, MD, Linda Harris, MD, Maciej Dryjski, MD, Hasan H. Dosluoglu, MD.
SUNY at Buffalo, Buffalo, NY, USA.
OBJECTIVES: Endovascular (EV)-first approach for patients with CLTI requiring infrapopliteal level revascularization was reported to provide better amputation-free survival (AFS) than those treated with autologous vein bypass (AVB) in the BASIL-2 Trial. However, for patients who had single segment great saphenous vein (GSV) bypass the BEST-CLI Trial reported better major adverse limb event or mortality free survival (MALE-M-FS) than EV-first group. The goal of this study is to compare real world outcomes in these patients who were selected to have ev or open revascularization as the initial revascularization based on medical comorbidities and disease complexity.
METHODS: All patients who had infrapopliteal revascularization with/without proximal intervention at a single site for Rutherford 4-6 between 1/2004-3/2024 were included. Group I had AVB-first (N=166, 158 GSV, 8 arm vein, 22.3%), and Group II had EV-first (N=577, 77.7%). AFS, MALE-M-FS, overall survival and limb salvage (LS) were compared before and after propensity score matching.
RESULTS: Patients in Group II were older (68.7±9.4vs73.9±10.1,P<0.001) had more CAD (60.0vs48.8% P<0.001), CKD (45.8vs27.1%,P<0.001), DM
(76.1%vs50.0%,P<0.001) and tissue loss (92.0%vs63.9%,P<0.001) whereas Group I had more COPD (25.3vs13.0,P<0.001) and multilevel revascularization
(72.9vs54.8%,P<0.001). Perioperative mortality was higher in Group I (4.2%vs2.3%, P=0.168). Mean follow-up was 43.5±43.9 months (range 0-225
months). The 24, 48 and 72 month AFS (72±4%vs47±2%, 48±4%vs31±2%, 33±4%vs20±2%, P<0.001), MALE-M-FS (65±4%vs41±2%, 43±4%vs26±2%, 28±4%vs16±2%, P<0.001), overall survival (76±3%vs56±2%, 54±4%vs38±2%, 39±4%vs24±2%, P<0.001) and LS (93±2%vs83±2%, 87±3%vs78±2%, 87±3%vs78±2%, P=0.006) were all significantly better in Group I than Group II. After propensity score matching, 119 patients in each group were similar in clinical presentation and comorbidities, with more TASC D disease in open group (TASC D 100% vs 55%, P<0.001). There were no differences in AFS (Figure), MALE-M-FS, overall survival and LS in propensity matched groups.
CONCLUSIONS: In patients with CLTI requiring infrapopliteal level revascularization, only 22% underwent AVB first, which provided better limb-based and patient-based outcomes. However, outcomes were similar when patients were matched for clinical presentation and comorbidities, suggesting that differences may be related to comorbid conditions rather than the procedure. Highly individualized revascularization strategy rather than dogmatic preferences allows optimization of outcomes in patients with CLTI undergoing tibial level intervention.
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