A Propensity-Matched Analysis of Endovascular Intervention versus Open Nonautologous Bypass as Initial Therapy in Patients with Chronic Limb-Threatening Ischemia

Autor: John Futchko, John Denesopolis, Patricia Friedmann, Saadat Shariff, Karan Garg, Evan C. Lipsitz, Eric B. Trestman, John P. Phair, Larry Scher, Francis J. Porreca
Rok vydání: 2021
Předmět:
Male
medicine.medical_specialty
Time Factors
medicine.medical_treatment
Clinical Decision-Making
Ischemia
030204 cardiovascular system & hematology
Revascularization
Risk Assessment
Amputation
Surgical
030218 nuclear medicine & medical imaging
Blood Vessel Prosthesis Implantation
Peripheral Arterial Disease
03 medical and health sciences
0302 clinical medicine
Risk Factors
medicine
Humans
cardiovascular diseases
Propensity Score
Vein
Aged
Proportional hazards model
business.industry
Endovascular Procedures
Gold standard
General Medicine
Perioperative
Limb Salvage
medicine.disease
Blood Vessel Prosthesis
Surgery
Treatment Outcome
surgical procedures
operative
medicine.anatomical_structure
Amputation
Chronic Disease
Propensity score matching
cardiovascular system
Female
Stents
Cardiology and Cardiovascular Medicine
business
Zdroj: Annals of Vascular Surgery. 75:194-204
ISSN: 0890-5096
Popis: Endovascular therapies are increasingly used in patients with complex multilevel disease and chronic limb-threatening ischemia (CLTI). Infrageniculate bypass with autologous vein conduit is considered the gold standard in these patients. However, many patients often lack optimal saphenous vein, leading to the use of nonautologous prosthetic conduit. We compared limb salvage and survival rates for patients with CLTI undergoing first time revascularization with either open nonautologous conduit or endovascular intervention.We retrospectively reviewed consecutive patients undergoing first time endovascular or open surgical revascularization at our institution between 2009 and 2016. Patients were divided into endovascular intervention or open bypass with nonautologous conduit (NAC) cohorts. Primary endpoints were amputation-free survival (AFS), freedom from reintervention, primary patency, and overall survival. Propensity scoring was used to construct matched cohorts. Outcomes were evaluated using Kaplan-Meier and Cox Proportional Hazards models.A total of 125 revascularizations were identified. There were 65 endovascular interventions and 60 NAC bypasses. In unmatched analysis, there was an elevated risk of perioperative MI (7% vs. 0%, P = 0.05) and amputation (10% vs. 2%, P = 0.04) for the NAC groups compared to the endovascular group. In matched analysis, endovascular patients had a lower incidence of 30-day amputation (1.5% vs. 10% P = 0.04) and length of stay (median days, 1 vs. 9, P0.01) compared to the open cohort. While not statistically significant, the endovascular group trended towards increased rates of two-year AFS (76% vs. 65%, P = 0.07) compared to the NAC group. There was no significant difference in overall survival when the endovascular cohort was compared to NAC (85% vs. 77%, P = 0.29) patients. In matched Cox analysis, nonautologous conduit use was associated with an increased risk of limb loss (HR 2.03, 95% CI 0.94-4.38, P = 0.07) compared to endovascular revascularization.An "endovascular first" approach offers favorable perioperative outcomes and comparable AFS compared to NAC and may be preferable when autologous conduit is unavailable.
Databáze: OpenAIRE
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