Stenting better than bypass at preventing reintervention in PAD

Patients with peripheral artery disease (PAD) who undergo femoral-popliteal bypass may be more likely to need additional intervention than patients treated with angioplasty and stenting, researchers found in a study published in the August issue of the Journal of Vascular Surgery. Patients requiring bypass, they hypothesized, may have more severe disease.

Mahmoud B. Malas, MD, and his colleagues at Johns Hopkins Bayview Medical Center in Baltimore, looked at the medical records of all patients admitted to the medical center with intermittent claudication, pain at rest, tissue loss or lower extremity gangrene between 2005 and 2012.

In their study, they included 104 patients who experienced symptoms and underwent percutaneous transluminal angioplasty/stenting (PTA/S) of the superficial femoral artery (SFA) or femoral-popliteal bypass after medical management was not successful. They followed each patient for an average of about two years and compared the two groups using the outcomes of patency and need for reintervention.

Most of the PTA/S procedure patients had TransAtlantic Inter-Society Consensus (TASC) II A and B lesions. The majority of the bypass patients had TASC C and D lesions.

“Open bypass remains the treatment gold standard for revascularization of the lower extremity,” the authors wrote. “Nevertheless, over the last decade there has been a significant shift in the treatment paradigm with an endovascular first approach on all patients evolving in many centers.”

They found that at 24 months, patency was better in the PTA/S group than in the bypass group (67 percent vs. 49 percent). In addition, patients who received stents had a lower reintervention rate over the two-year follow-up period (54 percent vs. 31 percent).

There were several reintervention methods. Angioplasty was performed for vein grafts with stenotic lesions shorter than 3 cm. For longer lesions or if there was restenosis after two angioplasty procedures, open patch angioplasty or interposition vein grafts occurred. Angioplasty on its own was used for in-stent restenosis and intimal hyperplasia. Restenting occurred only for fractured stents.

“This is the first study that demonstrates a higher rate of reintervention for femoral-popliteal bypass compared with angioplasty and stenting,” the authors wrote. “It also clearly demonstrates that the two patient populations are not equivalent, with much more extensive disease treated in the bypass cohort.”

The researchers added that a prospective randomized trial comparing the two treatment types is currently underway at their institution.