Polytetrafluoroethylene (PTFE) Tibial/Peroneal Arterial Bypass Grafting has Improved Cardiovascular Outcomes Compared to Primary Amputation
Nicholas J. Gargiulo III, MD FACS RPVI RVT RDMS1, Frank J. Veith2, Evan C. Lipsitz3, Neal Cayne4, Gregg Landis5.
1Clinch Valley Health, Richlands, VA, USA, 2Cleveland Clinic, Cleveland, OH, USA, 3Montefiore Medical Center, Bronx, NY, USA, 4NYU, NY, NY, USA, 5Northwell Health, NY, NY, USA.
Background: Polytetrafluoroethylene (PTFE) tibial and peroneal arterial bypasses may have improved cardiovascular outcomes compared to primary amputation.
Methods: A retrospective analysis was performed on a group of 23,391 patients with critical limb ischemia requiring revascularization between July 1977 and January 2017. in this cohort, 443 patients underwent tibial/peroneal PTFE arterial grafting without any adjunctive procedure and 103 patients underwent primary amputation. Cumulative life table primary and secondary patency and limb salvage rates were calculated for those bypasses performed between July 1977 through June 1987 (Group I). These were compared to those performed between July 1987 through June 1997 (Group II) and July 1997 through June 2017 (Group III). Ethnic background, TASC distribution, hemoglobin A1C levels, and inflammatory mediators (CRP, IL-6, and IL-10) were measured in a subset of Group III patients. Multivariate logistic regression was used to calculate intergroup differences with significance determined as P<0.02.
Results: Five- and 10-year primary patency and five- and 10-year limb salvage for Group I patients was 28.6%, 9%, and 55.0%, 27% respectively, for Group II patients was 27.3%, 9.9%, and 50.0%, and 26%, respectively, and for Group III patients was 34.0%, 11%, 73.3%, and 33% respectively. Patency and limb salvage for Group III patients exceeded that observed in Group I and II patients which correlated with the implementation of several perioperative strategies. Group III patients manifested a statistically better outcome compared to Group I and II patients. Interestingly, Group III patients manifested a greater distribution of TASC II D atherosclerotic disease and a greater percentage of Latino patients compared to Group I and II patients, and in this subset of patients had a trend towards a statistically worse five- and 10-year primary patency and five- and 10-year limb salvage rate (P=0.12). There was no direct correlation between hemoglobin A1C level, PTFE patency or successful limb salvage rates in any of the Groups (P>0.02). There was a trend towards a statistical correlation to PTFE graft patency and inflammatory mediators (CRP, IL-6 and IL-10, P=0.17). Those patients undergoing PTFE bypass had a reduced 30 day and 1 year MI, stroke, death and readmission rate compared to the primary amputation group.
Conclusions: PTFE bypasses without adjunctive procedures to infrapopliteal arteries has improved cardiovascular outcomes compared to patients undergoing primary amputation.
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