PMID- 28844467
OWN - NLM
STAT- MEDLINE
DCOM- 20180621
LR  - 20221207
IS  - 1097-6809 (Electronic)
IS  - 0741-5214 (Print)
IS  - 0741-5214 (Linking)
VI  - 67
IP  - 1
DP  - 2018 Jan
TI  - Patient selection and perioperative outcomes of bypass and endovascular 
      intervention as first revascularization strategy for infrainguinal arterial 
      disease.
PG  - 206-216.e2
LID - S0741-5214(17)31770-6 [pii]
LID - 10.1016/j.jvs.2017.05.132 [doi]
AB  - OBJECTIVE: The optimal initial revascularization strategy remains uncertain for 
      patients with peripheral arterial disease. The purpose of this study was to 
      evaluate current nationwide selection and perioperative outcomes of patients 
      undergoing bypass or endovascular intervention for infrainguinal disease in those 
      with no prior ipsilateral revascularization. METHODS: Patients undergoing 
      nonemergent first-time infrainguinal revascularization were identified in the 
      Targeted Vascular module of the National Surgical Quality Improvement Program 
      (NSQIP) for 2011 to 2014 and stratified by symptom status (chronic 
      limb-threatening ischemia [CLTI] or claudication). Patients treated with 
      endovascular intervention were compared with those who underwent bypass. 
      Multivariable logistic regression was used to evaluate current selection of 
      patients and to establish independent associations between first-time procedures 
      and postoperative outcomes. RESULTS: Of 5998 first-time infrainguinal 
      revascularizations performed, 3193 were bypass procedures (63% for CLTI) and 2805 
      were endovascular interventions (64% for CLTI). Current patient characteristics 
      associated with an endovascular-first approach as opposed to bypass-first in CLTI 
      patients were age >/=80 years, tissue loss, nonsmoking, functional dependence, 
      diabetes, dialysis, and tibial lesions, whereas age >/=80 years, nonwhite race, 
      nonsmoking, diabetes, and tibial lesions were associated with an endovascular 
      approach for claudication. In comparing first-time endovascular intervention with 
      bypass, there was no difference in 30-day mortality in CLTI patients (univariate: 
      2.1% vs 2.2%; adjusted: odds ratio [OR], 0.7; 95% confidence interval [CI], 
      0.4-1.1) or claudication patients (0.3% vs 0.6%). Among CLTI patients, 
      endovascular-first intervention was associated with lower rates of major adverse 
      cardiovascular event (3.6% vs 4.7%; OR, 0.6; 95% CI, 0.4-0.9), surgical site 
      infection (0.9% vs 7.7%; OR, 0.1; 95% CI, 0.1-0.2), bleeding (8.5% vs 17%; OR, 
      0.4; 95% CI, 0.3-0.5), unplanned reoperation (13% vs 17%; OR, 0.7; 95% CI, 
      0.5-0.8), and unplanned readmission (17% vs 18%; OR, 0.8; 95% CI, 0.7-0.9). 
      Patients with claudication undergoing endovascular-first intervention also had 
      lower rates of major adverse cardiovascular event (0.8% vs 1.6%; OR, 0.4; 95% CI, 
      0.2-0.95), surgical site infection (0.7% vs 6.6%; OR, 0.1; 95% CI, 0.04-0.2), 
      bleeding (2.3% vs 6.0%; OR, 0.3; 95% CI, 0.2-0.5), unplanned reoperation (4.3% vs 
      6.6%; OR, 0.6; 95% CI, 0.4-0.9), and unplanned readmission (5.9% vs 9.0%; OR, 
      0.6; 95% CI, 0.4-0.8). Conversely, endovascular-first intervention was associated 
      with a higher rate of secondary revascularizations within 30 days for CLTI (4.3% 
      vs 3.1%; OR, 1.6; 95% CI, 1.04-2.3) but not for claudication (2.6% vs 1.9%; OR, 
      1.7; 95% CI, 0.9-3.4). CONCLUSIONS: An endovascular-first approach as a 
      revascularization strategy for infrainguinal disease was associated 
      with substantially lower early morbidity but not mortality, at the cost of higher 
      rates of postoperative secondary revascularizations. As a national representation 
      of first-time revascularizations, this study highlights the early endovascular 
      perioperative benefit, although more robust long-term data are needed to adopt 
      either one strategy or the other in select patients with peripheral arterial 
      disease.
CI  - Copyright (c) 2017 Society for Vascular Surgery. Published by Elsevier Inc. All 
      rights reserved.
FAU - Bodewes, Thomas C F
AU  - Bodewes TCF
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of 
      Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
FAU - Darling, Jeremy D
AU  - Darling JD
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass.
FAU - Deery, Sarah E
AU  - Deery SE
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of 
      Surgery, Massachusetts General Hospital, Boston, Mass.
FAU - O'Donnell, Thomas F X
AU  - O'Donnell TFX
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of 
      Surgery, Massachusetts General Hospital, Boston, Mass.
FAU - Pothof, Alexander B
AU  - Pothof AB
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of 
      Vascular Surgery, University Medical Center, Utrecht, The Netherlands.
FAU - Shean, Katie E
AU  - Shean KE
AD  - Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel 
      Deaconess Medical Center, Harvard Medical School, Boston, Mass.
FAU - Moll, Frans L
AU  - Moll FL
AD  - Department of Vascular Surgery, University Medical Center, Utrecht, The 
      Netherlands.
FAU - Schermerhorn, Marc L
AU  - Schermerhorn ML
AD  - Division of Vascular and Endovascular Surgery, Department of 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  - Journal Article
PT  - Research Support, N.I.H., Extramural
DEP - 20170824
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/statistics & numerical data
MH  - Endovascular Procedures/adverse effects/methods/*statistics & numerical data
MH  - Female
MH  - Humans
MH  - Ischemia/*surgery
MH  - Limb Salvage/adverse effects/methods/*statistics & numerical data
MH  - Lower Extremity/*blood supply/surgery
MH  - Male
MH  - Middle Aged
MH  - Odds Ratio
MH  - Patient Selection
MH  - Perioperative Period
MH  - Peripheral Arterial Disease/mortality/*surgery
MH  - Postoperative Complications/epidemiology/etiology
MH  - Registries/*statistics & numerical data
MH  - Reoperation/statistics & numerical data
MH  - Retrospective Studies
MH  - Risk Assessment
MH  - Risk Factors
MH  - Time Factors
MH  - Treatment Outcome
MH  - Vascular Grafting/adverse effects/methods/*statistics & numerical data
PMC - PMC5741492
MID - NIHMS893733
EDAT- 2017/08/29 06:00
MHDA- 2018/06/22 06:00
PMCR- 2019/01/01
CRDT- 2017/08/29 06:00
PHST- 2017/02/12 00:00 [received]
PHST- 2017/05/31 00:00 [accepted]
PHST- 2017/08/29 06:00 [pubmed]
PHST- 2018/06/22 06:00 [medline]
PHST- 2017/08/29 06:00 [entrez]
PHST- 2019/01/01 00:00 [pmc-release]
AID - S0741-5214(17)31770-6 [pii]
AID - 10.1016/j.jvs.2017.05.132 [doi]
PST - ppublish
SO  - J Vasc Surg. 2018 Jan;67(1):206-216.e2. doi: 10.1016/j.jvs.2017.05.132. Epub 2017 
      Aug 24.