Study Compares Bypass, Angioplasty for SFA Disease

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For intermittent claudication due to superficial femoral artery (SFA) disease, bypass surgery and angioplasty each have pros and cons, according to a single-center study published online February 10, 2012, ahead of print in the Journal of Vascular Surgery. Bypass shows early disadvantages for length of stay and wound infection but offers better symptom relief and freedom from restenosis over the long term.

Marc L. Schermerhorn, MD, of Beth Israel Deaconess Medical Center (Boston, MA), and colleagues retrospectively reviewed their hospital’s experience in performing lower extremity bypass procedures between 2001 and 2009 and angioplasty cases between 2005 and 2009. The researchers excluded all limb salvage procedures and looked only at patients undergoing their first intervention for SFA disease-related claudication. Follow-up duration averaged 25 months after bypass and 18 months after angioplasty.

Different at Baseline, After Treatment

In all, 113 bypass graft surgeries were included, 62% above the knee and 38% below the knee. Veins were used in 73% of cases and prosthetic material in the remaining 27%. Angioplasty was performed in 105 patients, 57% of whom received stents.

Although technical success was achieved in all cases, the mean length of stay was higher after bypass than after angioplasty (3.9 days vs. 1.2 days; P < 0.01). The bypass group also experienced more wound infection (16% vs. 0; P < 0.01), although 82% of cases were superficial and treated successfully with short courses of antibiotics. The remainder, meanwhile, did not involve the grafts.

Long-term outcomes favored bypass surgery, which saw greater freedom from restenosis and symptom recurrence at 3 years. Freedom from reintervention was similar between groups, as was survival (table 1).

Table 1. Three-Year Outcomes

Less severe lesions tended to be treated percutaneously. Forty percent of angioplasty cases involved lesions classified as Trans-Atlantic Inter-Society Consensus (TASC) A compared with 17% of bypass cases. TASC C lesions, meanwhile, were more common in the bypass group than in the angioplasty group (36% vs. 11%), as were TASC D lesions (13% vs. 3%; P < 0.01 for all comparisons).

On multivariable analysis, angioplasty use independently predicted restenosis (HR 2.5; 95% CI 1.4-4.4) and symptom recurrence (HR 3.0; 95% CI 1.8-5). TASC D lesion class was similarly associated with higher risks of restenosis (HR 3.7; 95% CI 3.5-9) and symptom recurrence (HR 3.1; 95% CI 1.4-7). Statin use, documented in 62% of bypass patients and 69% of angioplasty patients, also appeared protective against restenosis (HR 0.6; 95% CI 0.35-0.97) and symptom recurrence (HR 0.6; 95% CI 0.36-0.93).

“Our results show that, despite the national trend toward endovascular intervention as the first-line treatment for claudication, surgical bypass remains an effective and durable option for patients with low postoperative morbidity and mortality,” Dr. Schermerhorn and colleagues conclude, noting that statin use should be standard in all patients treated for claudication.

No ‘One Size Fits All’

In an e-mail communication, Dr. Schermerhorn told TCTMD that surgeons at Beth Israel Deaconess have had a long history with lower extremity bypass. And over the past decade, the physicians “have shifted to an aggressive stance toward endovascular intervention and have built one of the largest experiences with lower extremity angioplasty and stenting,” he said, adding that the large academic tertiary referral center also sees a large proportion of diabetics.

Based on the current findings, Dr. Schermerhorn stressed that the 2 procedures are not equivalent and that physicians should weigh certain factors when choosing between them.

“Those at risk for significant [wound infections] or other complications or with a poor conduit and less extensive disease may be better candidates for angioplasty,” he advised, “while those with a good conduit and without significant risk of [infections] or other morbidity may benefit from bypass.”

Asked how the study’s observational design might affect comparisons, Dr. Schermerhorn pointed out that, “[i]n this case, there is certainly a bias in favor of [angioplasty] in that patients with less extensive disease based on TASC class were more likely to undergo [that procedure], while those with more extensive disease were more likely to undergo bypass. This simply strengthens the findings and conclusions.”

Future research should focus on the costs and cumulative morbidity of primary and subsequent interventions, particularly multiple sequential vascular procedures or bypass after angioplasty, the paper suggests.

With this information, Dr. Schermerhorn said, the most cost-effective therapy could be selected based on patient and lesion characteristics prior to the first intervention.

Study Details

Baseline patient characteristics were similar between the 2 groups. However, those who had bypass tended to be younger (mean age 63 years vs. 69 years; P < 0.01) and to have congestive heart failure (7% vs. 0; P < 0.01). Conversely, surgery patients were less likely than angioplasty patients to have hypertension (75% vs. 82%; P < 0.05).

 

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Source:
Siracuse JJ, Giles KA, Pomposelli FB, et al. Long-term results for primary bypass versus primary angioplasty/stent for intermittent claudication due to superficial femoral artery occlusive disease. J Vasc Surg. 2012;Epub ahead of print.

 

 

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