title: Growing impact of restenosis on the surgical treatment of peripheral arterial disease.
abstract: BACKGROUND
  Patients with peripheral arterial disease often experience treatment failure from restenosis at the site of a prior peripheral endovascular intervention (PVI) or lower extremity bypass (LEB). The impact of these treatment failures on the utilization and outcomes of secondary interventions is poorly understood.
  
  
  RESULTS
  In our regional vascular quality improvement collaborative, we compared 2350 patients undergoing primary infrainguinal LEB with 1154 patients undergoing secondary infrainguinal LEB (LEB performed after previous revascularization in the index limb) between 2003 and 2011. The proportion of patients undergoing secondary LEB increased by 72% during the study period (22% of all LEBs in 2003 to 38% in 2011, P<0.001). In-hospital outcomes, such as myocardial infarction, death, and amputation, were similar between primary and secondary LEB groups. However, in both crude and propensity-weighted analyses, secondary LEB was associated with significantly inferior 1-year outcomes, including major adverse limb event-free survival (composite of death, new bypass graft, surgical bypass graft revision, thrombectomy/thrombolysis, or above-ankle amputation; Secondary LEB MALE-free survival = 61.6% vs primary LEB MALE-free survival = 67.5%, P=0.002) and reintervention or amputation-free survival (composite of death, reintervention, or above-ankle amputation; Secondary LEB RAO-free survival = 58.9% vs Primary LEB RAO-free survival 64.1%, P=0.003). Inferior outcomes for secondary LEB were observed regardless of the prior failed treatment type (PVI or LEB).
  
  
  CONCLUSIONS
  In an era of increasing utilization of PVI, a growing proportion of patients undergo LEB in the setting of a prior failed PVI or surgical bypass. When caring for patients with peripheral arterial disease, physicians should recognize that first treatment failure (PVI or LEB) affects the success of subsequent revascularizations.
authors.affiliation: Department of Surgery, New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY.
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Jones
authors.forename: Andres
authors.initials: A
authors.lastname: Schanzer
authors.forename: Yuanyuan
authors.initials: Y
authors.lastname: Zhao
authors.forename: Todd A
authors.initials: TA
authors.lastname: MacKenzie
authors.forename: Brian W
authors.initials: BW
authors.lastname: Nolan
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D003251:Constriction, Pathologic; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D009203:Myocardial Infarction / Q000209:etiology; D009511:New England; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D012008:Recurrence; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000639:trends
keywords: angioplasty; bypass; peripheral vascular disease; restenosis; revascularization; stents