PMID- 28274753 OWN - NLM STAT- MEDLINE DCOM- 20170731 LR - 20221207 IS - 1097-6809 (Electronic) IS - 0741-5214 (Print) IS - 0741-5214 (Linking) VI - 66 IP - 2 DP - 2017 Aug TI - Results for primary bypass versus primary angioplasty/stent for lower extremity chronic limb-threatening ischemia. PG - 466-475 LID - S0741-5214(17)30192-1 [pii] LID - 10.1016/j.jvs.2017.01.024 [doi] AB - BACKGROUND: Long-term results comparing percutaneous transluminal angioplasty with or without stenting (PTA/S) and open surgical bypass for chronic limb-threatening ischemia (CLTI) in patients who have had no prior intervention are lacking. METHODS: All patients undergoing a first-time lower extremity revascularization for CLTI by vascular surgeons at our institution from 2005 to 2014 were retrospectively reviewed. Outcomes included perioperative complications, wound healing, restenosis, primary patency, reintervention, major amputation, RAS events (ie, reintervention, major amputation, or stenosis), and mortality. Outcomes were evaluated using chi(2), Kaplan-Meier, and Cox regression analyses. RESULTS: Of the 2869 total lower extremity revascularizations performed between 2005 and 2014, there were 1336 that fit our criteria of a first-time lower extremity intervention for CLTI (668 bypass procedures and 668 PTA/S procedures). Bypass patients were younger (71 vs 72 years; P = .02) and more often male (62% vs 56%; P < .02). Total mean hospital length of stay (LOS) was significantly longer after a first-time bypass (10 vs 8 days; P < .001), as were mean preoperative LOS (4 vs 3 days; P < .01) and postoperative LOS (7 vs 5 days; P < .001). There was no difference in perioperative mortality (3% vs 3%; P = .63). Surgical site infection occurred in 10% of bypass patients. Freedom from reintervention was significantly higher in patients undergoing a first-time bypass procedure (62% vs 52% at 3 years; P = .04), as was freedom from restenosis (61% vs 45% at 3 years; P < .001). Complete wound healing at 6-month follow-up was significantly better after an initial bypass (43% vs 36%; P < .01). A Cox regression model of all patients showed that reintervention was predicted by a first-time PTA/S (hazard ratio, 1.6; 95% confidence interval, 1.3-2.1) and both preoperative femoropopliteal TransAtlantic Inter-Society Consensus (TASC) C and TASC D lesions (2.0 [1.3-3.1] and 1.8 [1.3-2.7], respectively). Major amputation among all patients was predicted by an initial presentation of gangrene (2.5 [1.3-5.0]), dialysis dependence (1.9 [1.3-2.9]), diabetes (2.0 [1.1-3.8]), and preoperative femoropopliteal TASC D lesions (2.1 [1.1-4.0]) and was not predicted by procedure type. CONCLUSIONS: In this retrospective analysis, bypass for the primary treatment of CLTI showed improved 6-month wound healing, higher freedom from restenosis, improved patency rates, significantly fewer reinterventions, and higher survival than PTA/S within 3 years; however, a bypass-first approach was associated with increased total hospital LOS and wound infection. Perioperative mortality and amputation rates were similar between procedure types. CI - Copyright (c) 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved. FAU - Darling, Jeremy D AU - Darling JD AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - McCallum, John C AU - McCallum JC AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Soden, Peter A AU - Soden PA AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Korepta, Lindsey AU - Korepta L AD - Michigan State University College of Human Medicine, East Lansing, Mich. FAU - Guzman, Raul J AU - Guzman RJ AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Wyers, Mark C AU - Wyers MC AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Hamdan, Allen D AU - Hamdan AD AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. FAU - Schermerhorn, Marc L AU - Schermerhorn ML AD - Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass. Electronic address: mscherm@bidmc.harvard.edu. LA - eng GR - T32 HL007734/HL/NHLBI NIH HHS/United States PT - Comparative Study PT - Journal Article PT - Research Support, N.I.H., Extramural DEP - 20170306 PL - United States TA - J Vasc Surg JT - Journal of vascular surgery JID - 8407742 SB - IM MH - Aged MH - Aged, 80 and over MH - Amputation, Surgical MH - Angioplasty, Balloon/adverse effects/*instrumentation/mortality MH - Blood Vessel Prosthesis MH - *Blood Vessel Prosthesis Implantation/adverse effects/instrumentation/mortality MH - Boston MH - Chi-Square Distribution MH - Chronic Disease MH - Female MH - Humans MH - Ischemia/diagnostic imaging/mortality/physiopathology/*therapy MH - Kaplan-Meier Estimate MH - Length of Stay MH - Limb Salvage MH - Lower Extremity/*blood supply MH - Male MH - Middle Aged MH - Multivariate Analysis MH - Peripheral Arterial Disease/diagnostic imaging/mortality/physiopathology/*therapy MH - Postoperative Complications/etiology MH - Proportional Hazards Models MH - Recurrence MH - Retrospective Studies MH - Risk Factors MH - Saphenous Vein/*transplantation MH - *Stents MH - Time Factors MH - Treatment Outcome MH - Vascular Patency MH - Wound Healing PMC - PMC5524588 MID - NIHMS857486 EDAT- 2017/03/10 06:00 MHDA- 2017/08/02 06:00 PMCR- 2018/08/01 CRDT- 2017/03/10 06:00 PHST- 2016/09/28 00:00 [received] PHST- 2017/01/04 00:00 [accepted] PHST- 2017/03/10 06:00 [pubmed] PHST- 2017/08/02 06:00 [medline] PHST- 2017/03/10 06:00 [entrez] PHST- 2018/08/01 00:00 [pmc-release] AID - S0741-5214(17)30192-1 [pii] AID - 10.1016/j.jvs.2017.01.024 [doi] PST - ppublish SO - J Vasc Surg. 2017 Aug;66(2):466-475. doi: 10.1016/j.jvs.2017.01.024. Epub 2017 Mar 6.