H. J. Leraas1, S. S. Adkar1, Z. Sun1, B. F. Gilmore1, U. P. Nag1, C. A. Long1, W. S. Jones1, C. K. Shortell1, R. S. Turley1 1Duke University Medical Center,Durham, NC, USA
Introduction: Consensus guidelines regarding optimal treatment of infrapopliteal arterial disease for critical limb ischemia (CLI) lack specificity with respect to surgical and endovascular interventions. Evidence that endovascular approaches to infrapopliteal disease are associated with lower 30-day morbidity than open surgical bypass consists predominantly of small case series without matched surgical comparisons. The objective of this study is to compare the 30-day outcomes of patients treated with endovascular or open interventions for infrapopliteal disease.
Methods: The 2011-2013 NSQIP Vascular database was queried for CLI patients undergoing femoral distal bypass, popliteal distal bypass, or tibial angioplasty. Surgical patients were propensity matched 2:1 to tibial angioplasty using the nearest neighbor method. Variables for matching were age, race, BMI, elective vs. emergency surgery, ASA class, rest pain vs. ischemic tissue loss, diabetes, renal failure, dialysis, wound classification, and smoking. Primary endpoints were 30-day major adverse events (death, stroke, MI), or major amputation. Secondary endpoints were post-operative wound complications, length of stay, and readmission.
Results: 317 endovascular patients were matched to 634 surgery patients. Types of surgery were femoral distal bypass with prosthetic (28%), femoral distal bypass with saphenous vein (48%), and popliteal distal bypass with saphenous vein (24%). All endovascular patients underwent tibial angioplasty/stenting. Median age (95% CI) was 54 (45-63) and 53 (44-62) years and median BMI (95% CI) was 27 (24-31) and 27 (24-31) for surgery and endovascular, respectively. Tissure loss was present in 77% of surgery patients and 80% of endovascular patients, with all remaining having rest pain. The need for emergency intervention (3.9% vs. 3.8%) was similar in both groups. While there were no significant differences in major amputation or 30-day mortality between the treatment groups, surgery had a higher incidence of combined stroke/MI (4.6% vs. 1.3%, p=0.009), post-operative wound infection (12.8% vs 7.3%, p =.01), and longer median hospital stay (8 days vs 3 days, p <.001). Surgery patients were also more likely to be discharged to a skilled care facility (25.9% vs 12.6%, p<.001) or be readmitted (4.4% vs 3.2%, p=.024). (Table 1)
Conclusion: Endovascular treatment of infrapopliteal disease with CLI has similar 30-day major amputation and mortality with fewer stroke/MIs, wound infections, hospital days and readmissions compared to surgery. Long term comparisons are needed to provide objective data on which to form consensus guidelines for the optimal treatment for critical limb ischemia due to infrapopliteal arterial disease.
