title: Below-knee endovascular interventions have better outcomes compared to open bypass for patients with critical limb ischemia.
abstract: Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008-2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60-0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80-1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44-1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease.
authors.affiliation: 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: 2 Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Alireza
authors.initials: A
authors.lastname: Najafian
authors.affiliation: 3 Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA.
authors.forename: Alik
authors.initials: A
authors.lastname: Farber
authors.affiliation: 4 Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Menard
authors.affiliation: 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Mahmoud B
authors.initials: MB
authors.lastname: Malas
authors.affiliation: 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
authors.affiliation: 1 Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Abularrage
mesh_terms: D000368:Aged; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D007866:Leg / Q000098:blood supply*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016016:Proportional Hazards Models; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000009:adverse effects / Q000401:mortality; D014654:Vascular Patency
keywords: angioplasty; critical limb ischemia (CLI), bypass grafting; lower extremity; peripheral arterial disease (PAD); popliteal artery; registries; tibial artery; treatment outcome; vascular surgical procedures