Preservation for Future use of the Autologous Saphenous Vein during femoro-popliteal Bypass Surgery is Inexpedient

Endovascular Revascularisation versus Open Surgery with Prosthetic Bypass for Femoro-Popliteal Lesions in Patients with Peripheral Arterial Disease

Aim: Complex atherosclerotic femoro-popliteal lesions have traditionally been treated with bypass surgery. A prosthetic graft is used to save the vein graft for more distal revascularisations or when a vein graft is unavailable. The endovascular approach has gained popularity and is offered as a first-line strategy for complex lesions. This study aimed to evaluate whether endovascular procedures can be used as a first-line treatment strategy for complex native femoro-popliteal lesions over open surgery with prosthetic bypass in patients with peripheral arterial disease (PAD). Methods: This single-centre retrospective observational study was conducted between 2013 and 2021; it included patients with symptomatic PAD who required limb revascularisation at the femoro-popliteal segment and who had complex lesions. The primary endpoints analysed were technical success, primary patency, freedom from clinically driven target lesion revascularisation (cdTLR), freedom from major adverse limb and cardiovascular events (MALE and MACE, respectively), freedom from limb loss, and survival. The secondary endpoints were length of in-hospital stay, and duration and costs of the procedure. Results: We identified 185 limbs among 174 suitable candidates for comparison, wherein 105 were treated with an endovascular procedure and 80 with a femoro-popliteal prosthetic bypass. Most patients in both groups presented with chronic limb-threatening ischaemia, and >90% of them had an American Society of Anesthesiologists (ASA) physical status classification of >3. The endovascular group had more octogenarians (p = 0.02) and patients with coronary disease (p = 0.004). The median follow-up was 30 months. The technical failure rate for endovascular procedures was 4.7%, versus 0% in the open group (p = 0.047). Freedom from MACE was similar in both groups. The endovascular group showed superior primary patency (p < 0.0001), cdTLR (p < 0.0001), MALE (p < 0.0001), and freedom from limb loss (p = 0.0018) at 24 and 48 months. Further analysis performed for the open above-the-knee sub-group showed that the aforementioned endpoints were similar between the groups at 12 months and were better in the endovascular group at 24 and 48 months. Procedural time and in-hospital stay were longer in the open group than in the endovascular group (p < 0.0001 and p < 0.001, respectively). The procedural cost in the endovascular group was 10-fold lower than that in the prosthetic bypass group. Conclusions: Endovascular procedures are safe for treating complex femoro-popliteal lesions in patients at a high risk for surgery and show better outcomes at 24 months than prosthetic bypasses do. The latter may be considered as an alternative should endovascular treatment fail.

Vein Versus Prosthetic Graft for Femoropopliteal Bypass Above the Knee: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Conflicting evidence exists surrounding which conduit material is preferable in above-knee femoropopliteal bypass surgery. We performed a systemic review of electronic information sources to identify randomized controlled trials (RCTs) comparing vein versus prosthetic grafts in above-knee femoropopliteal bypasses. Eight RCTs reporting 1271 grafts (608 saphenous vein and 663 prosthetic) in 1132 patients were included. At 5 years, the vein group had significantly higher primary patency (odds ratio [OR]: 1.73, 95% confidence interval [CI]: 1.17-2.55, P = 0.006), primary assisted patency (OR: 4.02, 95% CI: 2.84-5.70, P < 0.0001), and secondary patency (OR: 1.83, 95% CI: 1.20-2.80, P = 0.005) rates compared with the prosthetic group. The vein group required significantly fewer reinterventions (OR: 0.33, 95% CI: 0.18-0.60, P = 0.0003). There was no significant difference in 30-day mortality (risk difference: −0.01, 95% CI: −0.02 to 0.01, P = 0.34), 30-day morbidity (OR: 1.58, 95% CI: 0.61-4.06, P = 0.35), major amputation (OR: 0.71, 95% CI: 0.43-1.18, P = 0.19), or overall survival (OR: 0.95, 95% CI: 0.70-1.30, P = 0.76) when comparing vein versus prosthetic grafts. Our analysis supports the use of the saphenous vein in above-knee femoropopliteal bypass grafting owing to its superiority in primary, primary assisted, and secondary patency rates and less need for reintervention when compared with prosthetic grafts.

PTFE bypass or thrupass for superficial femoral artery occlusion? A randomised controlled trial

Early results of a thrupass endograft in the treatment of femoral lesions are promising. Less morbidity and better cost-effectiveness are suggested to be achieved in the treatment of chronic lower limb ischaemia with endovascular treatment compared to surgical treatment.

PATIENTS AND METHODS

This randomised multicentre trial aimed to enroll a group of 60+60 patients for the treatment of 5-25-cm occlusions of superficial femoral artery (SFA) to be followed up for 3 years. Patients were treated either with endoluminal PTFE thrupass (WL Gore & Ass) or with surgical polytetrafluoroethylene (PTFE) bypass to proximal popliteal artery. Primary patency at 3 years was scheduled to be the primary end-point and secondary patency, functional success, costs and quality of life the secondary end-points.

RESULTS

A sample of 100 consecutive SFA occlusions in one of the centres revealed that only 4% of the lesions were amenable for the study. The trial was prematurely terminated due to the results of an interim analysis at the time when 44 patients were recruited: the 1-year primary patency (excluding technical failures) was 48% for thrupass and 95% for bypass (p=0.02). The patency difference in favour of surgical bypass over endovascular thrupass was also sustained after completion of 1-year follow-up, the primary patencies being 46% and 84% at 1 year with grossly equilinear life-table curves thereafter (p=0.18), respectively. The corresponding secondary patencies were 63% and 100% (p=0.05) when excluding technical failures and 58% and 100% (p=0.02) according to intention-to-treat analysis. Secondary outcomes were thus not analysed.

CONCLUSION

Treatment of SFA occlusions (TASC IIB and C or Imelda Ia and II) should be done by PTFE bypass rather than by PTFE thrupass, as thrupass is connected with worse early outcome. These results represent only a small category of femoral disease.