title: Bypass surgery or percutaneous transluminal angioplasty to treat critical lower limb ischaemia due to infrainguinal arterial occlusive disease?
abstract: OBJECTIVE
  To define the role of bypass surgery and percutaneous transluminal angioplasty to manage critical limb ischaemia due to infrainguinal arterial occlusive disease.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Regional hospital, Hong Kong.
  
  
  METHODS
  Consecutive patients treated for critical limb ischaemia, for whom data were prospectively collected in those who underwent: (i) infrainguinal percutaneous transluminal angioplasty first, or (ii) infrainguinal bypass surgery.
  
  
  RESULTS
  Among patients with critical lower limb ischaemia, 364 consecutive individuals having infrainguinal bypass operations and 100 having percutaneous transluminal angioplasty first were compared. The latter patients were older (77 vs 74 years, P=0.014) and had more co-morbidities but higher ankle pressure than those having bypass surgery. In the angioplasty-first group, 74% had favourable lesions (classified as TransAtlantic Inter-Society Consensus A/B). In the bypass group, operative mortality was higher (4% vs 1%, P=0.03) than that in the angioplasty-first group. Hospital mortality was comparable (8% vs 3%, P=0.15). In the bypass group, median hospital stay was longer than that in the angioplasty-first group (24 vs 4 days, P<0.001), and postoperatively they also had a higher median ankle-brachial index (0.92 vs 0.70, P<0.001) and superior long-term patency. In the bypass group, American Society of Anesthesiologists class 4 patients suffered very high operative and hospital mortality (15% and 31%, respectively). Long-term patency of percutaneous transluminal angioplasty depended on the TransAtlantic Inter-Society Consensus class of the treated lesion. Limb salvage rates at 3 years were 89% and 78% for percutaneous transluminal angioplasty first and surgical bypass, respectively (P=0.046). Long-term survival was poorer in the percutaneous transluminal angioplasty-first group (21% vs 51% at 5 years, P=0.04).
  
  
  CONCLUSIONS
  Infrainguinal bypass and percutaneous transluminal angioplasty are complementary. For TransAtlantic Inter-Society Consensus A and B lesions, percutaneous transluminal angioplasty should be offered first. For American Society of Anesthesiologists class 4 patients, percutaneous transluminal angioplasty should be considered first, regardless of the TransAtlantic Inter-Society Consensus class.
authors: Pedder Clinic, 25th Floor, 26 Nathan Road, Kowloon, Hong Kong. dr_ahchong@yahoo.com.hk
authors: A K
authors: AK
authors: Ah Chong
authors: C B
authors: CB
authors: Tan
authors: Maket W C
authors: MW
authors: Wong
authors: Florence S K
authors: FS
authors: Cheng
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000628:therapy*; D016009:Chi-Square Distribution; D002908:Chronic Disease; D005260:Female; D006801:Humans; D007511:Ischemia / Q000209:etiology / Q000628:therapy*; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage / Q000379:methods; D008297:Male; D016491:Peripheral Vascular Diseases / Q000150:complications / Q000628:therapy*; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000379:methods*