Outcomes, Practice Patterns in Lower Extremity Bypass Patients Studied

Proportionally, More Bypasses for Critical Limb Ischemia Rather Than Intermittent Claudication

Newswise — CHICAGO - Seven researchers, on behalf of the Vascular Study Group of New England (VSGNE) reviewed VSGNE data of 2,907 patients who had infrainguinal lower extremity bypasses (LEBs) between 2003 and 2009. Of these patients, 72 percent of the procedures were for critical limb ischemia (CLI) and 28 percent were for intermittent claudication (IC). Details of the research were reported in the June issue of the Journal of Vascular Surgery®.
Co-author Philip P. Goodney, MD, MS, a vascular surgeon from the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., along with colleagues, Jessica Simons, MD, Andres Schanzer, MD, from the University of Massachusetts, Worcester, and other investigators in the VSGNE noted that the proportion of patients who underwent LEB for IC increased significantly (from 19 percent to 31 percent) during the study period. There also was a significant increase in the proportion of LEBs performed after a previous endovascular intervention among both CLIs (from 11 percent to 24 percent) and ICs (from 13 percent to 23 percent.)
"At one year follow-up, amputation-free survival (AFS) was the primary endpoint defined as freedom from ipsilateral major amputation and freedom from all-cause mortality,” said Dr. Goodney. “There was no significant AFS change in patients with IC (97 percent in 2003 and 98 percent in 2008; P for trend .63) or in patients with CLI (73 percent in 2003 and 81 percent in 2008; P _ .10). Neither in-hospital mortality, graft patency nor cardiac event rates changed significantly among either group.”
Researchers said that although LEB is still more commonly performed for CLI, the proportion of patients receiving surgical bypass for IC has increased significantly. The exact cause of this shift in practice patterns is unknown but more patients with CLI may undergo endovascular intervention as an initial revascularization strategy. If true, they said, this more aggressive posture toward endovascular therapy might have led to a decrease in the number of patients with CLI requiring a surgical bypass.
“If the proportion of patients with IC receiving endovascular intervention instead of LEB is not increasing at the same rate as patients with CLI, the relative proportion of patients with CLI undergoing LEB compared to patients with IC would decrease,” said Dr. Goodney. “More information is needed about outcomes of patients receiving endovascular intervention only. It also would be useful to know the indication for prior endovascular intervention, particularly to identify patients with CLI for whom the endovascular procedure was for IC but the disease subsequently progressed to CLI when the LEB was performed.”
Dr. Goodney added that the observed change in practice pattern may be a shift in strategies for treating IC and it may be that an increasing number of patients with IC are offered percutaneous revascularization or surgeons may feel obliged to perform an open revascularization if a prior endovascular approach has not succeeded in symptom resolution.
“Determining what is an appropriate application of endovascular interventions and surgical bypass for both CLI and IC remains controversial, and outcomes from large regional quality improvement dataset are critical to help make informed treatment decisions,” added Dr. Goodney. “Therefore, we sought to define the early and 1-year outcomes of LEB in a large, multicenter regional cohort, and analyze trends in the use of LEB with or without prior endovascular interventions.”
“Our regional quality improvement initiative has been modified in order to begin collecting data for future study, to review both open and endovascular treatment strategies, and eventually even disease- based registries that incorporate both treated and untreated patients with both claudication and CLI,” noted Dr. Goodney. “We want to further understand the volume and outcomes of open and endovascular revascularization for IC and CLI, and how better to identify patient subgroups that will benefit most from each revascularization strategy.
# # #
About Journal of Vascular Surgery®Journal of Vascular Surgery® provides vascular, cardiothoracic and general surgeons with the most recent information in vascular surgery. Original, peer-reviewed articles cover clinical and experimental studies, noninvasive diagnostic techniques, processes and vascular substitutes, microvascular surgical techniques, angiography and endovascular management. Special issues publish papers presented at the annual meeting of the Journal's sponsoring society, the Society for Vascular Surgery®. Visit the Journal Web site at http:www.jvascsurg.org/.
About the Society for Vascular SurgeryThe Society for Vascular Surgery® (SVS) is a not-for-profit professional medical society, composed primarily of vascular surgeons, that seeks to advance excellence and innovation in vascular health through education, advocacy, research, and public awareness. SVS is the national advocate for 3,370 specialty-trained vascular surgeons and other medical professionals who are dedicated to the prevention and cure of vascular disease. Visit its Web site at www.VascularWeb.org® and follow SVS on Twitter by searching for VascularHealth or at http://twitter.com/VascularHealth.