Results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease.
BACKGROUND
Percutaneous transluminal angioplasty ± stent (PTA/S) and surgical bypass are both accepted treatments for claudication due to superficial femoral artery (SFA) occlusive disease. However, long-term results comparing these modalities for primary intervention in patients who have had no prior intervention have not been reported. We report our results with 3-year follow-up.


METHODS
We reviewed all lower extremity bypass procedures at Beth Israel Deaconess Medical Center from 2001 through 2009 and all PTA/S performed from 2005 through 2009 for claudication. We excluded all limb salvage procedures and included only those that were undergoing their first intervention for claudication due to SFA disease. We recorded patient demographics, comorbidities, perioperative medications, TASC classification, and runoff. Outcomes included complications, restenosis, symptom recurrence, reinterventions, major amputation, and mortality.


RESULTS
We identified 113 bypass grafts and 105 PTA/S of femoral-popliteal lesions without prior interventions. Bypasses were above the knee in 62% (45% vein) and below the knee in 38% (100% vein). Mean age was 63 (bypass) versus 69 (PTA/S; P < .01). Mean length of stay (LOS) was 3.9 versus 1.2 days (P < .01). Bypass grafts were used less for TASC A (17% vs 40%; P < .01) and more for TASC C (36% vs 11%; P < .01) and TASC D (13% vs 3%; P < .01) lesions. There were no differences in perioperative (2% vs 0%; not significant [NS]) or 3-year mortality (9% vs 8%; NS). Wound infection was higher with bypass (16% vs 0%; P < .01). None involved grafts. Bypass showed improved freedom from restenosis (73% vs 42% at 3 years; hazard ratio [HR], 0.4; 95% confidence interval [CI], .23-.71), symptom recurrence (70% and 36% at 3 years; HR, 0.37; 95% CI, .2-.56), and freedom from symptoms at last follow-up (83% vs 49%; HR, 0.18; 95% CI, .08-.40). There was no difference in freedom from reintervention (77% vs 66% at 3 years; NS). Multivariable analysis of all patients showed that restenosis was predicted by PTA/S (HR, 2.5; 95% CI, 1.4-4.4) and TASC D (HR, 3.7; 95% CI, 3.5-9) lesions. Recurrence of symptoms was similarly predicted by PTA/S (HR, 3.0; 95% CI, 1.8-5) and TASC D lesions (HR, 3.1; 95% CI, 1.4-7). Statin use postoperatively was predictive of patency (HR, 0.6; 95% CI, .35-.97) and freedom from recurrent symptoms (HR, 0.6; 95% CI, .36-.93).


CONCLUSIONS
Surgical bypass for the primary treatment of claudication showed improved freedom from restenosis and symptom relief despite treatment of more extensive disease, but was associated with increased LOS and wound infection. Statins improved freedom from restenosis and symptom recurrence overall.
Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA 02210, USA.
Jeffrey J
JJ
Siracuse
Kristina A
KA
Giles
Frank B
FB
Pomposelli
Allen D
AD
Hamdan
Mark C
MC
Wyers
Elliot L
EL
Chaikof
April E
AE
Nedeau
Marc L
ML
Schermerhorn
D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000379:methods*; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D015331:Cohort Studies; D005260:Female; D005263:Femoral Artery; D005500:Follow-Up Studies; D006801:Humans; D007383:Intermittent Claudication / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D007902:Length of Stay; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy; D011237:Predictive Value of Tests; D011859:Radiography; D012008:Recurrence; D012189:Retrospective Studies; D018570:Risk Assessment; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000379:methods*