IYSC09 - Open Bypass Is Superior to Endovascular Revascularization in Patients Undergoing Reintervention for Chronic Limb Threatening Ischemia Using a Medicare-Linked Database

Objectives: The need for re-interventions following lower extremity revascularization (LER) is common, ranging from 13-85% depending on different follow-up periods. Prior literature has detailed the outcomes of bypass therapy (BT) and endovascular therapy (ET) for initial LER for chronic limb-threatening ischemia (CLTI). Nonetheless, there is a paucity of data regarding the best revascularization technique for patients undergoing re-intervention following prior revascularization. This study aims to describe the outcomes of BT versus ET in patients with prior open or endovascular LER.

Methods: We identified all patients with a history of prior ipsilateral LER who had undergone redo LER for CLTI from 2010 to 2019 in the VQI-VISION database. Patients who had undergone suprainguinal procedures were excluded. Study groups included: BT versus ET in patients with prior ET and BT versus ET in patients with prior BT.

Results: A total of 17,145 patients had undergone prior ET with 69.7% undergoing redo ET and 30.3% undergoing BT, and 15,905 patients had undergone prior BT with 83.7% undergoing ET and 16.3% undergoing redo BT. Among patients with prior ET, Patients undergoing BT were more likely to be smokers (79% vs 67.1%, P< 0.001), present with rest pain (38.8% vs 27%, P< 0.001), and lower ankle-brachial index (ABI) (0.6 ± 0.6 vs 0.8 ± 0.6, P< 0.001). BT was associated with a lower risk of one-year major amputation/death (aHR: 0.75, 95%CI(0.7-0.8), P< 0.001), ACM (aHR: 0.8, 95%CI(0.7-0.9), P< 0.001), major amputation (aHR: 0.7, 95%CI(0.6-0.8), P< 0.001), and revascularization (aHR: 0.76, 95%CI(0.7-0.9), p< 0.001). Among patients with prior BT, redo BT patients were more likely to be smokers (86.2% vs 67.7%, P< 0.001), present with rest pain (46.7% vs 27.8%, P< 0.001), and lower ABI (0.5 ± 0.5 vs 0.8 ± 0.6, P< 0.001). Redo BT was associated with improved one-year major amputation/death (aHR: 0.8, 95%CI(0.7-0.9), P< 0.001), ACM (aHR: 0.7, 95%CI(0.67-0.8), P< 0.001), major amputation (aHR: 0.8, 95%CI(0.7-0.9), P=0.008), and revascularization (aHR: 0.76, 95%CI(0.7-0.8), p< 0.001). These results persisted at 5 years (Table 1, Figure 1).

Conclusions: The present study shows that revascularization with ET is performed more frequently in patients with prior BT or ET. Despite a higher percentage of smoking, rest pain, and lower ABI in patients undergoing redo BT, BT had better outcomes with improved limb salvage, durability, AFS, and ACM compared with redo ET. Future prospective studies are needed to confirm our findings.