A systematic review and meta-analysis of primary bypass surgery compared with bypass surgery after endovascular treatment in peripheral artery disease patients

Bypass After Failed Endovascular Intervention Is Associated with an Increased Risk of Above Ankle Amputation Among Patients with Chronic Limb Threatening Ischaemia in a Randomised Trial Population

OBJECTIVE

One concern about the endovascular first (ENDO) approach for chronic limb threatening ischaemia (CLTI) is whether bridges are burned for a secondary bypass (SB) if required in the future. This secondary analysis of a prospective randomised trial aimed to compare above ankle amputation rates in patients with CLTI treated with primary bypass (PB) compared with those treated with SB after an initial ENDO approach.

METHODS

Data from the randomised unblinded Best Endovascular versus Best Surgical Therapy of Patients with CLTI (BEST-CLI) trial were analysed. Patients were included if they had CLTI and were considered as candidates for open or ENDO revascularisation with the primary outcomes being major adverse limb free event survival. There were two parallel cohorts based on whether single segment great saphenous vein (SSGSV) was (cohort 1) or was not (cohort 2) available. Primary bypass was compared with SB after index ENDO using the primary outcome of above ankle amputation with death as a competing risk. Multivariable and propensity matched analyses were performed.

RESULTS

There were 665 PB and 158 SB in cohort 1 and 192 PB and 45 SB in cohort 2. Time to SB after ENDO occurred at a median of 28 days in all patients and at a median of 210 days in those who had a successful initial ENDO procedure. Unadjusted one year analysis showed SB to be associated with increased above ankle amputation (14% vs. 8.1%; p = .002) overall. Secondary bypass was associated with increased above ankle amputation in cohort 1 (13.5% vs. 7.4%; p = .003), whereas this was not statistically significant in cohort 2 (15.9% vs. 10.9%; p = .28). These findings were confirmed on multivariable analysis (adjusting for age, sex, wound ischaemia foot infection stage, randomisation strata, diabetes mellitus, end stage kidney disease, previous index infrainguinal reconstruction, and smoking history) for cohort 1, with SB associated with increased above ankle amputation (HR 1.72, 95% CI 1.08 - 2.73; p = .020), remaining true when restricting to SB after a technically successful ENDO (HR 2.21, 95% CI 1.26 - 3.86; p =.005). Results were similar on propensity matched analyses.

CONCLUSION

In patients with CLTI deemed suitable for either open or ENDO, SB was associated with worse limb salvage compared with PB, particularly in patients with an available SSGSV.

Vascular Impairment, Muscle Atrophy, and Cognitive Decline: Critical Age-Related Conditions

The triad of vascular impairment, muscle atrophy, and cognitive decline represents critical age-related conditions that significantly impact health. Vascular impairment disrupts blood flow, precipitating the muscle mass reduction seen in sarcopenia and the decline in neuronal function characteristic of neurodegeneration. Our limited understanding of the intricate relationships within this triad hinders accurate diagnosis and effective treatment strategies. This review analyzes the interrelated mechanisms that contribute to these conditions, with a specific focus on oxidative stress, chronic inflammation, and impaired nutrient delivery. The aim is to understand the common pathways involved and to suggest comprehensive therapeutic approaches. Vascular dysfunctions hinder the circulation of blood and the transportation of nutrients, resulting in sarcopenia characterized by muscle atrophy and weakness. Vascular dysfunction and sarcopenia have a negative impact on physical function and quality of life. Neurodegenerative diseases exhibit comparable pathophysiological mechanisms that affect cognitive and motor functions. Preventive and therapeutic approaches encompass lifestyle adjustments, addressing oxidative stress, inflammation, and integrated therapies that focus on improving vascular and muscular well-being. Better understanding of these links can refine therapeutic strategies and yield better patient outcomes. This study emphasizes the complex interplay between vascular dysfunction, muscle degeneration, and cognitive decline, highlighting the necessity for multidisciplinary treatment approaches. Advances in this domain promise improved diagnostic accuracy, more effective therapeutic options, and enhanced preventive measures, all contributing to a higher quality of life for the elderly population.

International Cross-Sectional Survey ON TReatment Of Occluded Femoro-Popliteal Stents (SUNROOF)

PURPOSE

The aim of this project is to explore practice patterns of experienced vascular specialists involved in the treatment of patients with arterial femoro-popliteal in-stent occlusion (ISO) and to understand key concepts and shared thoughts, throughout an international cross-sectional survey.

MATERIALS AND METHODS

The web-based survey was in English and included 31 questions. One-hundred experts were invited by email to fill in the survey anonymously on Google Forms using a dedicated link. Reminders were sent after the first 2 weeks. In addition to reporting of pooled responses, subanalyses of answers were also performed, according to country of origin (European vs non-European), years of experience (≤20 years vs >20 years), and type of institution (Academic/University vs Non-academic/Private).

RESULTS

A total of 77 physicians from 22 countries completed the survey. Most responders were males (70/77, 91%). Most of the participants were vascular surgeons (58/77, 75%). Endovascular therapy was the preferred option in patients presenting with either acute limb ischemia, disabling intermittent claudication, or chronic limb-threatening ischemia. Atherectomy/thrombectomy+Drug-Coated Balloon (DCB) was the preferred endovascular modality (32/77, 42%). No differences between country of origin, years of experience, and type of institution of the participants were found.

CONCLUSIONS

The international SUrvey oN TReatment Of Occluded Femoro-Popliteal Stent (SUNROOF) survey has suggested that endovascular therapy is the preferred method for the treatment of femoro-popliteal ISO. This survey could represent a good starting point for future research on comparison between open and endovascular approach and different devices, which currently lacks good-level scientific evidence and appropriate guidelines.

CLINICAL IMPACT

The international SUNROOF survey included 31 questions. It was performed by 77 vascular physicians from 22 countries. More than a half of respondents considered an endovascular approach as the preferred treatment modality in acute limb ischemia, disabling intermittent claudication, or chronic limb-threatening ischemia. Most responders agreed they would intensify the follow-up protocol and anti-thrombotic medications regimen after a first in-stent occlusion episode. This survey could represent a good starting point for future research on comparison between open and endovascular approach and different devices, which currently lacks of good level scientific evidence and appropriate guidelines.

An Endovascular- Versus a Surgery-First Revascularization Strategy for Chronic Limb-Threatening Ischemia: A Meta-Analysis of Randomized Controlled Trials

Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results. We conducted a trial-level meta-analysis to compare the outcomes between endovascular-first and surgery-first strategies for revascularization. PubMed, Web of Science, and the Cochrane Library were searched to identify RCTs comparing the outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RRs) with 95% confidence intervals were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using the pooled aggregated data from published curves, with their corresponding hazard ratios (HRs) and 95% confidence intervals reported for up to 5 years of follow-up. A total of 3 RCTs with 2,627 patients (1,312 endovascular-first and 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 patients (70.9%) were men and 347 (13.2%) were older than 80 years. Comparing the endovascular-first and surgery-first approaches, there was no significant difference in the overall (HR 0.92 [0.83 to 1.01], p = 0.09) or amputation-free survival (HR 0.98 [0.92 to 1.03], p = 0.42), reintervention (RR 1.24 [0.74 to 2.07], p = 0.41), major amputation, (RR 1.16 [0.87 to 1.54], p = 0.31), or therapeutic crossover (RR 0.92 [0.37 to 2.26], p = 0.85). In conclusion, data from available RCTs suggest that there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight.