Real-World Comparison of Popliteal-Distal Bypass Versus Tibial Endovascular Therapy for Chronic Limb-Threatening Ischemia Secondary to Infrapopliteal Occlusive Disease
Recommended Citation
Chamseddine H, Halabi M, Shepard A, Hoballah JJ, Nypaver T, Weaver M, Boules T, Kavousi Y, Onofrey K, Saleem H, Kabbani L. Real-World Comparison of Popliteal-Distal Bypass Versus Tibial Endovascular Therapy for Chronic Limb-Threatening Ischemia Secondary to Infrapopliteal Occlusive Disease. J Vasc Surg 2025; 81(6):e298.
Document Type
Conference Proceeding
Publication Date
6-1-2025
Publication Title
J Vasc Surg
Abstract
Objective: Chronic limb-threatening ischemia (CLTI) secondary to infrapopliteal occlusive disease can be treated with surgical bypass or endovascular therapy (ET). The Bypass vs Angioplasty in Severe Ischemia of the Leg-2 (BASIL-2) trial demonstrated improved amputation-free survival (AFS) when ET was used as the initial treatment. However, most patients screened for the trial were deemed not eligible for randomization in BASIL-2. We aim to analyze real-world data to compare the outcomes of popliteal-distal bypass (PDB) vs tibial artery ET for isolated infrapopliteal occlusive disease. Methods: Patients undergoing PDB and tibial artery ET for CLTI were identified in the Vascular Quality Initiative between 2010 and 2023. Only bypasses using single-segment great saphenous vein from a popliteal inflow were included. Tibial artery ET included transluminal balloon angioplasty, atherectomy, and/or stenting of the tibial vessels; patients with a more proximal peripheral vascular intervention were excluded. Patients who underwent PDB were one-to-three propensity score matched to patients who underwent isolated tibial artery ET. Kaplan-Meier and Cox regression analyses were used to evaluate the long-term outcomes of primary patency, major amputation, reintervention, mortality, major adverse limb evens, and AFS. Results: A total of 3478 patients who underwent PDB were matched to 10,434 patients who underwent tibial artery ET. After matching, the two groups were similar in all demographics and preoperative characteristics (Table). PDB was associated with higher perioperative morbidity, including higher rates of myocardial infarction (2.7% vs 0.4%, P < .001), acute kidney injury (7.1% vs 1.4%, P < .001), surgical site infection (3.1% vs 1.0%, P < .001), and perioperative mortality (1.5% vs 0.9%, P = .002). At 1-year follow-up, PDB was associated with higher primary patency (73% vs 69%, P < .001) and lower major amputation (13% vs 16%, P = .003), lower reintervention (14% vs 17%, P = .026), lower major adverse limb events (26% vs 30%, P < .001), and lower mortality (14% vs 17%, P < .001) compared with tibial artery ET. PDB was also associated with significantly improved AFS (70% vs 64%, P < .001), reflecting a 17% reduction in the relative risk of amputation/death for PDB compared with tibial artery ET (Fig). Conclusions: Using real-world data, this study suggests that PDB has superior 1-year primary patency and AFS compared with isolated tibial artery ET. PDB is a more durable and effective revascularization strategy despite having higher perioperative morbidity and mortality. Consideration for both revascularization options, inclusive of great saphenous vein assessment, remains crucial in optimizing and improving the long-term outcomes of patients with CLTI secondary to infrapopliteal occlusive disease. [Formula presented] [Formula presented]
Volume
81
Issue
6
First Page
e298
