Current efficacy of open and endovascular interventions for advanced superficial femoral artery occlusive disease

Background: There has been a marked paradigm shift in the treatment of symptomatic femoro-popliteal disease with a shift from open to endoluminal therapy. The consequence of this shift in therapy is poorly described. The aim of this study is to examine the clinical efficacy of this shift in treatment strategies. Methods: A database of patients undergoing open (OPEN) and endoluminal (ENDO) intervention for TASC II C and D femoro-popliteal lesions between 1990 and 2010 was retrospectively queried. Kaplan-Meier survival analyses were performed to assess time-dependent outcomes. Factor analyses were performed using a multivariant Cox proportional hazard model for time-dependent variables. Results: A total of 2593 limbs underwent either OPEN or ENDO treatment for symptomatic and anatomically advanced femoro-popliteal disease over a 20-year period. There was a two-fold rise in endovascular interventions between the first and second decade. In the first decade, 80% of the interventions were OPEN, while in the second decade, 61% of the interventions were ENDO. There were equivalent comorbidities in both groups, and survival was also equivalent. Endoluminal therapy was more commonly performed on claudicants. Thirty-day mortality was equivalent, but major morbidity was higher in OPEN compared with ENDO. Cumulative patency was equivalent in both groups with a similar reintervention rate. In contrast, clinical efficacy (freedom from recurrent symptoms, maintenance of ambulation, and avoidance of major amputation) was significantly higher in the OPEN group (P = .002). The presence of critical limb ischemia, diabetes, end-stage renal disease, and poor tibial runoff were predictors of poor anatomic and functional outcomes in both groups. Conclusions: There has been a marked shift in treatment modality for advanced femoro-popliteal disease with a lowering of the symptomatic threshold for intervention over 2 decades, likely spurred by the ease of endoluminal interventions. Although peri-procedural and anatomic outcomes for both procedures are equivalent, it appears that open surgery carries a superior long-term clinical efficacy. This superiority is negatively influenced by poor preoperative ambulation status, high modified Cardiac Risk Score, worse presenting symptoms, the occurrence of major adverse cardiovascular events, poor tibial runoff, the absence of hemodynamic success, and occlusion of the original bypass.