Meta-analysis Looks at Bypass vs. Endovascular Therapy for Femoropopliteal Lesions

In patients with femoropopliteal artery disease, endovascular therapy produces fewer early complications, but surgery holds a longer-term edge in fewer amputations and better overall survival, according to a meta-analysis published online November 16, 2012, ahead of print in the Journal of Vascular Surgery. The authors suggest that choice of treatment should be tailored to patients’ health status.

Researchers led by George A. Antoniou, MD, PhD, of Manchester Royal Infirmary (Manchester, United Kingdom), analyzed data from 2,817 patients, three-quarters with critical limb ischemia, from 4 randomized controlled trials and 6 observational studies conducted between 1989 and 2011 that compared open bypass surgery (n = 1,387)  vs. angioplasty (with or without stenting; n = 1,430).

Similar Early Mortality

The endovascular group was more likely to experience technical failure than the surgical group but had a lower rate of 30-day morbidity. Meanwhile, 30-day mortality was similar between the groups (table 1).

Table 1. Early Outcomes

Additionally, in 2 studies reporting data on hospital length of stay, endovascular treatment was associated with shorter stays compared with surgery (P < 0.001).

At 1-year post intervention, primary patency was higher in the surgical group compared with the endovascular group (OR 2.42; 95% CI 1.37-4.28; P = 0.002), a difference that persisted through year 3 (OR 1.48; 95% CI 1.12-1.97; P = 0.006).

Progression to amputation was more common in the endovascular group at the end of year 2 (95% CI 0.42-0.86; P = 0.005) and year 3 (95% CI 0.39-0.77; P = 0.001). By year 4, the surgery group had a clear advantage in higher amputation-free (OR 1.31; 95% CI 1.07-1.61; P = 0.009) and overall (OR 1.29; 95% CI 1.04-1.61; P = 0.020) survival compared with the endovascular approach.

Consistent with Prior Findings

According to the study authors, the findings are consistent with those of the large randomized BASIL (Bypass versus Angioplasty in Severe Ischemia of the Leg) trial, which concluded that for patients surviving for at least 2 years after randomization, a bypass-first strategy was associated with improved overall and amputation-free survival.

In terms of clinical implications, “an endovascular-first approach may be advisable in patients with significant comorbidity, who have a relatively short life expectancy,” the investigators add. Conversely, for fit patients with a longer life expectancy, “a bypass procedure, which seems to provide a more durable benefit, may be offered as a first-line treatment,” they write.

The authors stress, however, that other parameters, such as the type of bypass conduit available (prosthetic or vein) and the need for above- or below-the-knee intervention, should be considered before making a decision regarding open vs. endovascular intervention as first-line therapy for relatively healthy patients.

In conclusion, Dr. Antoniou and colleagues say that additional randomized controlled trials “evaluating the outcomes of surgical and endovascular treatment in carefully selected patients are required to delineate the efficacy of these methods for the treatment of femoropopliteal arterial disease.”

 

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Source:
Antoniou GA, Chalmers N, Georgiadis GS, et al. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg. 2012;Epub ahead of print.

 

 

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