Study Compares Endovascular Intervention and Surgery to Treat Symptomatic Lower Extremity PAD

October 6, 2015—Thomas T. Tsai, MD, et al published findings from an evaluation of the contemporary safety and effectiveness of peripheral endovascular interventions compared to lower extremity bypass surgery in the treatment of symptomatic peripheral artery disease (PAD). The study is available online ahead of print in Circulation.

According to the investigators, limited comparative effectiveness data exist between endovascular interventions and bypass surgery. This study compared the safety and effectiveness of the two strategies in patients with symptomatic claudication and critical limb ischemia.

The investigators concluded that in patients with symptomatic PAD, endovascular intervention was associated with fewer 30-day procedural complications, but patients had higher target lesion revascularization (TLR) rates at 1 and 3 years compared to bypass surgery. There was no difference in subsequent amputations.

As summarized in Circulation, the study included patients from a community-based clinical registry at two large integrated health care delivery systems. The investigators compared 883 patients undergoing endovascular intervention and 975 patients undergoing surgery between January 1, 2005 and December 31, 2011.

The rate of complications up to 30 days postprocedure for endovascular intervention and lower extremity bypass surgery was 11.9% versus 37.1% (P < .001).

In patients with claudication, the TLR rates for endovascular intervention were 12.3% ± 2.7% at 1 year and 19% ± 3.5% at 3 years compared to bypass surgery rates of 5.2% ± 2.4% at 1 year and 8.3% ± 3.1% at 3 years (log-rank P < .001). In patients with critical limb ischemia, TLR rates after endovascular interventions were 19.1% ± 4.8% at 1 year and 31.6% ± 6.3% at 3 years versus 10.8% ± 2.5% at 1 year and 16% ± 3.2% at 3 years after bypass surgery (log-rank P < .001).

Findings remained consistent in sensitivity analyses using propensity methods to account for treatment selection, reported the investigators in Circulation.

The Society for Vascular Surgery (SVS) addressed the findings from this study in a written statement. In the statement, SVS President Bruce A. Perler, MD, commented, “These results are not unexpected, and are certainly consistent with the information we’ve been developing from our Vascular Quality Initiative, which now includes more than 300,000 cases. While the less-invasive approach to treating arterial occlusive disease would be expected to be associated with a lower rate of complications—and this is obviously appealing to patients and practitioners—the implications of the higher rate of subsequent reinterventions should not be ignored and will become an increasingly important consideration as we enter this era of value-based reimbursement with an emphasis on longitudinal care and bundled payments in the American health care system.”