Fewer Infrainguinal Graft Revisions With OpenSurgery

By Sharon Worcester

RIO GRANDE, P.R. -- Surgical revisions appear to offer better durability than do endovascular revisions, particularly in the setting of occlusions, Dr. Scott A. Berceli reported at the annual meeting of the Southern Association for Vascular Surgery.

Although the endovascular approach may offer some benefit in regard to amputation and mortality, it does so at the expense of increased need for repeat revisions, and without improved quality of life or shorter hospital length of stay, he added.

The findings are from a nested cohort study of 1,404 patients from the Project of Ex-Vivo Vein Graft Engineering via Transfection (PREVENT) III trial who underwent infrainguinal vein bypass grafting for critical limb ischemia and who were followed for 1 year.

Of a total of 313 patients, 157 underwent open surgical revision, 134 had endovascular primary revision, and 22 had a combined surgical/endovascular revision and thus were included in the current analysis. With outcomes most closely approximating those in the surgical group, the combined endovascular/surgical patients were included with the open surgical patients in subsequent analysis, said Dr. Berceli of the division of vascular surgery at the University of Florida, Gainesville.

Patency status and lesion location did not differ significantly between the groups and did not affect the type of revision selected.

The time interval to revision was, however, significantly associated with method of repair, with surgical revision more common in those who required revision in the early postoperative period.

For example, in the 0- to 1-month postoperative period, 85% of the revisions were surgical and 15% were endovascular; and in the 3- to 12-month postoperative period, 47% were surgical and 53% were endovascular.

Overall survival following graft revision was significantly better in the surgical vs. endovascular patients (64% vs. 50%, respectively; hazard ratio 1.53), with one repeat revision required in about 15% vs. 25% of surgical and endovascular patients, respectively, and two repeat revisions required in about 8% and 3%, respectively. Only endovascular patients required three or more repeat revisions, with about 3% requiring three additional revisions, and about 1% requiring four additional revisions, Dr. Berceli said.

In thrombosed grafts undergoing salvage, graft survival was 88% vs. 39% at 12 months in the surgical vs. endovascular patients. In nonincluded grafts, the survival difference did not differ significantly in the two groups, but a trend toward divergence with improved survival in the surgical group was seen beginning at 7 months.

The endovascular patients did, however, show a trend toward decreased amputations and improved patient survival, with 12-month amputation-free estimates at 93% in the endovascular group vs. 88% in the surgical group, and with survival estimates at 95% in the endovascular group vs. 90% in the surgical group.

These differences did not reach statistical significance because of the low number of amputations and deaths in both groups, Dr. Berceli said.

Mean hospital lengths of stay in the current study were similar at 2.1 days in the surgical group and 1.7 days in endovascular group. Quality of life scores, as measured by the VascuQOL, were nearly equivalent for the two groups at baseline (2.7 in both groups) and at the end of the study (4.7 and 4.8 in the surgical and endovascular groups, respectively).

On multivariate analysis, significant predictors of endovascular graft revision failure included previous infrainguinal reconstruction (hazard ratio 3.2), conduit type-composite vein (hazard ratio 2.7), and proximal anastomosis-superficial femoral artery (hazard ratio 2.6).

Predictors of success included later time of revision from index graft placement (hazard ratio 0.99), statin use (hazard ratio 0.46), hypertension (hazard ratio 0.41), conduit length of 50-60 cm (hazard ratio 0.22), and institutional setting in Canada (hazard ratio 0.12).

The only significant predictor of surgical graft revision failure was the presence of multiple stenotic lesions (hazard ratio 2.7); predictors of success included diabetes (hazard ratio 0.45), private institution setting (hazard ratio 0.44), statin use (hazard ratio 0.42), hypertension (hazard ratio 0.42), and stage 3 renal insufficiency (hazard ratio 0.34).