Bypass versus Endovascular Therapy for Elective Infrapopliteal Interventions in Chronic Limb-Threatening Ischemia: Propensity Score-Matched Analyses of Vascular Quality Initiative Registry

Objective: We used multi-institutional data from the Vascular Quality Initiative (VQI) to compare outcomes following revascularization in infrapopliteal CLTI. Summary of Background Data: The choice between bypass and endovascular therapy (ET) in patients with chronic limb-threatening ischemia (CLTI) is controversial, particularly when the distal target is within the infrapopliteal region. Methods: We used VQI data (2018–2023) to compare bypass with single-segment great saphenous vein (SSGSV) vs. ET and bypass with an alternative conduit (AC) vs. ET in patients presenting with CLTI who underwent first-time elective infrapopliteal-only or femorotibial revascularizations. We performed two one-to-one propensity score matchings (PSM) in patients who had at least one follow-up. Two pairs of matched cohorts were created: SSGSV vs. ET and AC vs. ET. PSMs were conducted based on demographics, insurance status, smoking status, comorbidities, prior procedures, type of CLTI, and preoperative and discharge medications. The primary outcome was amputation-free survival (AFS). The secondary outcomes included overall survival (OS), limb salvage (LS), freedom from reintervention, freedom from major adverse limb event (MALE), and MALE-free survival. MALE was defined as any reintervention and/or major amputation following index revascularization. All outcomes were analyzed up to one-year. Kaplan-Meier survival estimates, and Cox regression were used for analyses. Results: There were 25,138 limbs and 21,339 patients. The interventions included: ET, N=21,506 (85.5%); SSGSV, N=2,299 (9.2%); and AC, N=1,333 (5.3%). After PSM, the SSGSV vs. ET (1,884 pairs) and AC vs. ET cohorts (1,038 pairs) were well balanced. In the matched cohorts, the SSGSV cohort was associated with decreased hazards of death (HR=0.73 [95% CI, 0.60–0.88]; P =0.001), and major amputation/death (HR=0.84 [95% CI, 0.72–0.97]; P =0.020) compared to the ET cohort. Moreover, the AC cohort was associated with increased hazards of major amputation (HR=1.82 [95% CI, 1.36–2.44]; P <.001), major amputation/death (HR=1.22 [95% CI, 1.01–1.46]; P =0.035), and MALE (HR=1.24 [95% CI, 1.02–1.51]; P =0.031) compared to the ET cohort. MALE/Death was not associated with the type of revascularization in matched cohorts. Conclusions: Our multi-institutional analyses revealed superior one-year outcomes with bypass using SSGSV compared to ET in terms of OS and AFS. However, ET was superior to bypass with AC in terms of LS, AFS, and freedom from MALE. We conclude that bypass with SSGSV should be considered first-line therapy for CLTI when there is infrapopliteal involvement. However, when a good quality SSGSV is not available, ET can offer lower amputation and MALE risk and higher AFS compared to AC. These decisions should be individualized based on each patient’s physiologic and anatomic factors.