title: Comparison of surgical bypass with angioplasty and stenting of superficial femoral artery disease.
abstract: OBJECTIVE
  To evaluate the contemporary outcome of femoral-popliteal bypass compared with angioplasty and stenting in patients with symptomatic peripheral arterial disease (PAD) in terms of patency and reintervention rates.
  
  
  METHODS
  We identified all patients evaluated at the Johns Hopkins Bayview Medical Center with the presumptive diagnosis of PAD from September 2005 to September 2010. In this group, we selected all symptomatic patients after failing medical management who received percutaneous transluminal angioplasty/stenting of the superficial femoral artery or femoral-popliteal bypass. We compared the overall patency and reintervention rates between the two groups as well as patency within TransAtlantic Inter-Society Consensus (TASC) II subgroups. Descriptive analyses were performed using χ(2) and two-sided t-tests. The Mann-Whitney U test was used to compare distributions of continuous variables and the Fisher exact test for categorical variables. Cox proportional hazard model was used to examine the treatment effect within each lesion type, using bypass as the reference group.
  
  
  RESULTS
  Out of 1237 patients evaluated at Johns Hopkins Bayview Medical Center for PAD from September 2005 to September 2010, we identified 104 symptomatic patients who received percutaneous transluminal angioplasty/stenting of the superficial femoral artery or femoral-popliteal bypass after failing medical management. There were 61 male patients (56%), and the mean age was 68 years in both groups. Both treatment groups had similar risk factors. Overall, 77% of patients with TASC II A and B lesions underwent angioplasty and stenting, whereas 73% of patients with TASC C and D lesions underwent bypass (P < .01). The primary patency at 24 months was better for the stent group 67% (95% confidence interval [CI], 0.52-0.78) vs bypass group 49% (95% CI, 0.32-0.64; P = .05). The rate of reintervention within the 2-year period was higher in the bypass group compared with the stent group (54% vs 31%; P = .02). TASC A and B lesions combined demonstrated a reduced hazard of patency failure compared with TASC C or D lesions combined (hazard ratio, 2.42; 95% CI, 1.26, 4.65; P < .01).
  
  
  CONCLUSIONS
  This is the first study that documents higher reintervention rates for femoral-popliteal bypass compared with angioplasty and stenting. We believe that the main reason for this finding is the fact that the bypass patients had significantly more advanced disease. This, emphasizes that one must consider the patient population undergoing intervention when comparing revascularization procedures. A prospective randomized trial is needed to determine the overall better treatment option.
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md. Electronic address: bmalas1@jhmi.edu.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Ngozi
authors.initials: N
authors.lastname: Enwerem
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Umair
authors.initials: U
authors.lastname: Qazi
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Brendan
authors.initials: B
authors.lastname: Brown
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Thomas
authors.initials: T
authors.lastname: Reifsnyder
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.affiliation: Department of Vascular and Endovascular Surgery, Johns Hopkins Bayview Medical Center and Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Perler
mesh_terms: D000368:Aged; D000800:Angioplasty, Balloon / Q000009:adverse effects / Q000295:instrumentation*; D015142:Baltimore; D019917:Blood Vessel Prosthesis Implantation; D016009:Chi-Square Distribution; D005260:Female; D005263:Femoral Artery / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery / Q000628:therapy*; D011183:Postoperative Complications / Q000628:therapy; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects; D014654:Vascular Patency; D014680:Veins / Q000637:transplantation*