When Are Endovascular and Open Bypass Treatments Preferred for Femoropopliteal Occlusive Disease?

Abstract

Several meta-analyses and multicenter trials have shown that chronic limb ischemia did not occur for up to 5 years in 50%-70% of patients who underwent saphenous vein grafts, with limb salvage and perioperative mortality rates of >80% and 3%, respectively. However, open surgical bypass can have limitations, including postoperative morbidity/ wound complications of 10%-20% and prolonged length of hospital stay and outpatient care. Several studies have analyzed clinical outcomes for patients with critical limb ischemia treated with endovascular therapies, but they have been mainly retrospective with significant heterogene-ity or were single center. Only few randomized trials have compared surgical vs. endovascular therapy. These included the Bypass vs. Angioplasty in Severe Ischemia of the Leg (BASIL) trial, with no differences found in amputation-free or overall survival rates at 1 year; however, late outcomes favored the surgical group. The Bypass or Angioplasty in Severe Intermittent Claudication (BASIC) trial concluded that the 1-year patency rates were 82% and 43% for bypass and angioplasty, respectively. The BEST Endovascular vs. Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) trial is currently enrolling patients. This review analyzed studies comparing open vs. endovascular therapy in patients with femoropopliteal disease. (This is a review article based on the invited lecture of the 45th Annual Meeting of Japanese Society for Vascular Surgery.) Keywords: endovascular vs. open bypass, femoropopliteal disease, endovascular treatment for PVD, open repair for PVD Peripheral arterial disease (PAD) is a steadily increasing global epidemic that affected more than 200 million patients worldwide in 2010. 1) More than three billion dollars is spent annually in the United States on healthcare for this disease, surpassing the amount spent on treating cardiovascular diseases. 2) A significant number of patients with PAD are asymptomatic; however, patients with intermittent claudication usually experience a limb loss rate of <5% over 5 years. Meanwhile, patients with critical limb ischemia (CLI) have a 1-year mortality and major amputation rates of 25% and 25%, respectively. 3) Barani reported a 25% mortality rate in hospitalized patients, primarily from cardiovascular disease (74%). 4) Therefore, when revascularization is needed in patients with claudication, informed discussion regarding outcomes is important, so that expectations regarding patency and need for reinter-vention are considered. Traditionally, femoropopliteal disease has been treated with open surgery (femoropopliteal bypass) over the last four to five decades with favorable 5-year patency rate when saphenous vein (ASV) grafts are used. Several meta-analyses and multicenter trials have shown that CLI did not occur for up to 5 years in 50%-70% of patients who underwent ASV grafting to tibial or pedal targets, with limb salvage and perioperative mortality rates of >80% and 3%, respectively. 5) A large retrospective study of 467 bypass grafts from 2004 to 2012 compared outcomes for ASV and polytet-rafluoroethylene (PTFE) grafts. During the 5-year follow-up, the patency rate with ASV was better than with PTFE grafts (82% vs. 26%, p<0.05). 6) Surgical bypass with PTFE should therefore be limited to patients with no other revascularization option. Meanwhile, the operative mortality is highly variable, which can range from 1.3% to 6.3%, which largely depends on cardiovascular risk, and should be considered preoperatively. Open surgical bypass can have important limitations,