title: Outcomes and practice patterns in patients undergoing lower extremity bypass.
abstract: BACKGROUND
  The appropriate application of endovascular intervention vs bypass for both critical limb ischemia (CLI) and intermittent claudication (IC) remains controversial, and outcomes from large, contemporary series are critical to help inform treatment decisions. Therefore, we sought to define the early and 1-year outcomes of lower extremity bypass (LEB) in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions.
  
  
  METHODS
  The Vascular Study Group of New England database was used to identify all infrainguinal LEB procedures performed between 2003 and 2009. The primary study endpoint was 1-year amputation-free survival (AFS). Secondary endpoints included in-hospital mortality and morbidity, including major adverse cardiac events. Trend analyses were conducted to identify annual trends in the proportion of LEBs performed for an indication of IC, in-hospital outcomes, including mortality and morbidity, and 1-year outcomes, including AFS. Analyses were performed on the entire cohort and then stratified by indication.
  
  
  RESULTS
  Between 2003 and 2009, 2907 patients were identified who underwent LEBs (72% for CLI; 28% for IC). The proportion that underwent LEB for IC increased significantly over the study period (from 19% to 31%; P < .0001). There was a significant increase over time in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11% to 24%; P < .0001) and ICs (from 13% to 23%; P = .02). Neither in-hospital mortality nor cardiac event rates changed significantly among either group. There was no significant change in 1-year AFS in patients with IC (97% in 2003 and 98% in 2008; P for trend .63) or in patients with CLI (73% in 2003 and 81% in 2008; P = .10).
  
  
  CONCLUSIONS
  Over the last 7 years, significant changes in patient selection for LEBs have occurred in New England. The proportion of LEBs performed for ICs as opposed to CLIs has increased. Patients are much more likely to have undergone prior endovascular interventions before undergoing a bypass. In-hospital and 1-year outcomes after LEB for both IC and CLI have remained excellent with no significant changes in AFS.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of Massachusetts, Medical School, Worcester, MA, USA.
authors.forename: Jessica P
authors.initials: JP
authors.lastname: Simons
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.forename: David H
authors.initials: DH
authors.lastname: Stone
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Kalish
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007383:Intermittent Claudication / Q000401:mortality / Q000601:surgery*; D007511:Ischemia / Q000401:mortality / Q000601:surgery*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D016014:Linear Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D009511:New England; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000209:etiology; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D012042:Registries; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality