Bypass better strategy for treating progressive, complex recurrent SFA disease: Study

Researchers from The Methodist Hospital's DeBakey Heart and Vascular Center in Houston, Texas have studied outcomes of patients who had endovascular and open interventions for recurrent superficial femoral artery (SFA) occlusive disease. Results of their work are detailed in the August issue of the Society for Vascular Surgery's® Journal of Vascular Surgery®.

A database of patients who underwent endovascular treatment of SFA between 1986 and 2008 was retrospectively queried and those with recurrent disease were selected. Outcomes were determined by Kaplan-Meier survival analyses and the Cox proportional hazard model for time dependent variables. A total of 735 limbs in 631 patients (64 percent were male with an average age of 67 years) underwent endovascular treatment for symptomatic SFA disease.

The lead author Mark G. Davies, MD, PhD, professor and vice chairman in The Methodist Hospital's Department of Cardiovascular surgery, said, "Of the 222 patients who developed restenosis (at a rate of 16±3 percent at 5 years), 58 remained asymptomatic and 164 underwent repeat interventions. Procedures included 59 percent percutaneous transluminal angioplasty (PTA) endovascular and 41 percent bypass procedures."

Bypass surgery was employed for critical ischemia (rest/pain/ tissue loss was 52 percent for repeat PTA vs. 75 percent for bypass) and in more extensive recurrent disease including TASC-II, C/D lesions (42 percent for repeat PTA vs. 67 percent bypass).

Critical ischemia, TASCII lesion category C and D and singlevessel tibial vessel runoff were significant predictors of failure in the repeat PTA group," added Dr. Davies. "In our study, primary and repeat PTA at five years had equivalent cumulative patency (73±9 percent vs. 73±3 percent; mean±SEM) and duration of symptom relief (66+3 percent vs. 63+6 percent). However, those undergoing bypass surgery showed significantly superior outcomes in patency and symptom relief (93±8 percent and 81±8 percent respectively) albeit with a higher morbidity (28 percent vs. 16 percent)."

Re-intervention is required in a minority of patients selected for SFA angioplasty and is associated with similar outcomes to the primary intervention," said Dr. Davies. "Some of these patients do show progression of their disease and bypass is more commonly used in these patients with superior long-term outcomes. Although early primary failure of six months or less is linked to subsequent early failure of a subsequent bypass, this study suggests that bypass rather than repeat PTA may be the better strategy for treating progressive, complex recurrent SFA disease."