Bypass Surgery Provides Better Outcomes Compared with Endovascular Therapy in the Composite Endpoint Comprising Relief from Rest Pain, Wound Healing, Limb Salvage, and Survival after Infra-inguinal Revascularisation in Patients with Chronic Limb Threatening Ischaemia

Objective

The present study aimed to determine the factors related to relief from rest pain, wound healing, major adverse limb events (MALEs), and prognosis after infrainguinal revascularisation in patients with chronic limb threatening ischaemia (CLTI).

Methods

The data of patients who underwent infrainguinal revascularisation for CLTI between 2010 and 2020 was analysed retrospectively. The endpoint was the composite of relief from rest pain, wound healing, MALE, or death.

Results

A total of 234 limbs in 187 patients with CLTI were analysed. Of the 234 limbs, 149 (63.7%) underwent bypass surgery and 85 (36.3%) underwent endovascular therapy (EVT). The event free survival rates with respect to the composite endpoint at two years were 30.4% in the EVT and 48.5% in the bypass groups, respectively (p = .005). The event free survival rates at two years were 56.7% in bypass surgery and 29.5% in EVT in the indeterminate subgroup (p = .051). Multivariable analysis revealed that age (hazard ratio [HR] 1.03; 95% confidence interval [CI] 1.01 – 1.05; p < .001), coronary artery disease (CAD) (HR 1.45; 95% CI 1.01 – 2.07; p = .042), haemodialysis (HR 1.74; 95% CI 1.22 – 2.48; p = .002), Wound, Ischaemia and foot Infection stage (HR 1.34; 95% CI 1.07 – 1.68; p = .012), Global Limb Anatomical Staging System stage (HR 1.31; 95% CI 1.01 – 1.72; p = .043), EVT (HR 1.90; 95% CI 1.31 – 2.74; p < .001), Geriatric Nutritional Risk Index (HR 0.98; 95% CI 0.97 – 0.99; p = .021), and non-ambulatory status (HR 1.89; 95% CI 1.31 – 2.74; p < .001) were risk factors for the composite endpoint.

Conclusion

Bypass surgery is superior to EVT with respect to the composite endpoint including relief from rest pain, wound healing, MALE, or death. Bypass surgery may be considered as the treatment of choice, instead of EVT, in patients in the indeterminate group according to the Global Vascular Guidelines preferred revascularisation method.