COLORADO SPRINGS — Outcomes of percutaneous interventions to treat lower-extremity vascular disease have gotten so good in recent years that the endovascular approach has replaced traditional open bypass operations as first-line therapy at one major New York vascular surgery program.
“Our experience with these procedures in this patient population has taught us that a percutaneous approach can be beneficial in patients with limited longevity. It may offer improved quality of life over open surgical bypass and was generally preferred by patients because of its less invasive nature,” Dr. Brian G. DeRobertis said at the annual meeting of the American Surgical Association.
The benefits aren't confined to quality-of-life issues, either. Procedural mortality, long-term vascular patency, and limb salvage rates with percutaneous intervention today are at least as good as with open surgery, added Dr. DeRobertis, a vascular surgery fellow at New York-Presbyterian Hospital.
“Five years ago we did many more open surgical bypass procedures than endovascular ones. But over time percutaneous intervention has become our first-line modality in almost all patients, with open surgery reserved for failures of percutaneous therapy,” he said.
Dr. DeRobertis reported on 1,000 percutaneous interventions in 730 consecutive patients at the hospital during 2000-2006. A total of 830 were initial interventions; the rest were repeat procedures. All involved an overnight hospital stay. A total of 46% of interventions were for claudication. The remainder were for limb-threatening ischemia, one-third involving rest pain and two-thirds featuring tissue loss.
Overall, this was a relatively sick group of patients, Dr. DeRobertis said. In all, 85% had hypertension, 58% were diabetic, 52% had known coronary artery disease, and 22% had renal insufficiency. Their mean age was 71 years.
Claudicants tended to have more femoral/popliteal disease, whereas limb-threat patients were more likely to undergo tibial intervention. In the femoral region, the primary treatment modality was angioplasty with stent placement. In the popliteal and tibial regions, the preference was to avoid stents in favor of angioplasty and excisional atherectomy.
Overall 30-day mortality was 0.5%. The rate of major complications was 3.2%, with an 8.4% minor complication rate. “Those rates are certainly lower than those quoted in most series of open surgical bypass,” Dr. DeRobertis said.
No patient required emergency bypass after a failed percutaneous intervention.
The 3-year primary patency rate–that is, uninterrupted patency without reinterventions or prophylactic procedures–was close to 50% in the claudicants. Their secondary patency rate–an end point comprising all patients with primary patency, plus those who lost primary patency but had it restored by percutaneous means–was nearly 80%.
The 3-year amputation rate in claudicants was 0.5%.
Primary and secondary patency rates in the limb-threat patients were much lower. In fact, limb-threat as an indication for percutaneous intervention was the strongest predictor of loss of patency in a multivariate regression analysis. However, the 3-year limb salvage rate of 80% in the limb-threat group was similar to results reported for surgical bypass.
Why do limb-threat patients do worse? It may be, at least in part, because they tend to be sicker. They have significantly higher rates of diabetes, hypertension, and multilevel peripheral vascular disease, according to Dr. DeRobertis.
“Your results are terrific,” said Dr. Ronald M. Fairman, chief of vascular surgery and endovascular therapy at the University of Pennsylvania, Philadelphia. “I can tell you that from reviewing our results we're clearly not as good.”
Discussant Dr. Gregorio A. Sicard said that Dr. De-Robertis' series of percutaneous interventions for lower extremity vascular disease was the largest ever reported from a single center. He was particularly pleased to see that all cases were done by surgeons.
“The results are as good as or better than those in the literature for any smaller series reported by other specialists who do the procedures,” observed Dr. Sicard, professor of surgery and chief of the vascular surgery section at Washington University, St. Louis.
Some vascular surgeons have worried that a failed percutaneous intervention can make a patient worse and result in loss of the extremity, but Dr. DeRobertis' series shows that's not the case when the work is done well, he added.
All papers presented at the 127th annual meeting of the ASA are subsequently submitted to the Annals of Surgery for consideration.
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