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Prior Endovascular Intervention Is Not Associated With Unfavorable Outcomes In Infrainguinal Bypass Surgery For Chronic Limb Threatening Ischemia: A Propensity Score-Matched Analysis Of VQI-Medicare-Linked Database
Sina Zarrintan1, Daniel Willie-Permor1, Jeffrey Siracuse2, Andrew Barleben1, Mahmoud Malas1
1University of California, San Diego, LA JOLLA, CA;2Boston University School of Medicine, Boston Medical Center, Boston, MA

INTRODUCTION: Bypass with an autogenous vein is still considered the gold standard for patients with chronic limb threatening ischemia (CLTI). However, in the endovascular era, the majority of patients undergo a peripheral vascular intervention (PVI) as the first-line treatment. The aim of this study was to evaluate the impact of prior endovascular interventions on perioperative and long-term outcomes of infrainguinal bypass in patients with CLTI.
METHODS: Vascular Quality Initiative-Medicare-Linked Database was queried for all infrainguinal bypasses performed by autogenous grafts between 2011 to 2019 in CLTI patients with occlusive disease. Patients with concomitant suprainguinal procedures or acute limb ischemia were excluded. Patients with history of prior ipsilateral bypass or prior ipsilateral major amputation were also excluded. The remaining patients were stratified by presence or absence of history of prior PVI on the index limb. Primary outcomes were limb salvage (LS), freedom from index limb reintervention (ILR) and freedom from target lesion reintervention (TLR) at five years. Secondary outcomes were overall survival (OS) and amputation-free survival (AFS) at five years, in-hospital major adverse cardiovascular events (MACE), in-hospital major adverse limb events (MALE) and 30-day mortality. One-to-one propensity score-matched (PSM) analysis with 17 dimensions and caliber of 0.1 was performed to produce two well-matched cohorts. Logistic regression and generalized linear model were used to analyze the perioperative outcomes whereas Kaplan-Meier survival estimates and COX regression were used for analysis of long-term outcomes.
RESULTS: The study included two cohorts of patients with history of prior PVI (N=2,030, 29.0%) and patients without history of prior PVI (N=4,958, 71.0%). The mean age of patients with and without history of prior PVI was 70.39.9 and 71.69.5, respectively (Std Diff=0.133). PSM produced two well-matched cohorts with 1,544 pairs. After PSM, five-year LS was 81.9% vs. 81.4% (P=0.883), five-year freedom from ILR was 55.1% vs. 56.3% (P=0.610) and five-year freedom from TLR was 57.5% vs. 59.8% (P=0.478) in patients with and without history of prior PVI, respectively. OS and AFS were 51.9% vs. 47.3% (P=0.086) and 43.8% vs. 39.7% (P=0.241) in patients with and without history of prior PVI, respectively. In matched cohorts, long-term outcomes were not associated with the history of prior PVI (Table 1). Moreover, in-hospital MACE and MALE and 30-day mortality were not associated with history of prior PVI either before or after PSM (Table 2).
CONCLUSIONS: The results of this propensity score-matched analysis revealed that short- and long-term outcomes following lower extremity bypass in patients with CLTI are not affected by the prior endovascular interventions. This real world multi-institutional study suggests that endovascular-first strategy is a safe practice in patients presenting with CLTI; however, further prospective randomized studies are necessary to confirm our findings.

Table 1. Five-year outcomes (Reference=Without Prior PVI)
Before MatchAfter Match
OutcomeHR (95% CI)P-ValueHR (95% CI)P-Value
Major Amputation1.08 (0.93-1.26)0.3201.01 (0.83-1.24)0.883
Reintervention on Index Limb1.17 (1.06-1.29)0.0011.03 (0.91-1.17)0.610
Reintervention on Target Lesion1.19 (1.08-1.31)<0.0011.05 (0.92-1.19)0.478
All-Cause Mortality0.83 (0.75-0.91)<0.0010.89 (0.79-1.02)0.086
Major Amputation or Death0.91 (0.83-0.99)0.0380.93 (0.83-1.05)0.241

Table 2. Perioperative outcomes (Reference=Without Prior PVI)
Before Match
OutcomeDe Novo N=4,958 (71.0%)Prior PVI N=2,030 (29.0%)OR (95% CI)P-Value
MACE224 (4.5%)99 (4.9%)1.08 (0.83-1.41)0.556
MALE210 (4.3%)90 (4.5%)1.05 (0.82-1.35)0.703
30-Day Mortality117 (2.4%)49 (2.4%)1.02 (0.74-1.41)0.887
After Match
OutcomeDe Novo N=1,544 (50%)Prior PVI N=1,544 (50%)RR (95% CI)P-Value
MACE65 (4.2%)66 (4.3%)1.01 (0.73-1.42)0.932
MALE59 (3.8%)72 (4.7%)1.22 (0.87-1.71)0.247
30-Day Mortality25 (1.62)33 (2.14)1.32 (0.79-2.21)0.291


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