(IP179) Comparison of Bypass and Endovascular Treatment of Isolated Popliteal Artery Occlusive Disease in Patients with Chronic Limb-Threatening Ischemia: An Analysis of Vascular Quality Initiative Data

Objectives: Popliteal artery (PA) occlusive disease is common in patients with chronic limb-threatening ischemia (CLTI), and the results of endovascular therapy (ET) are less well defined in this segment. This study compares the outcomes of bypass with a single-segment great saphenous vein (SSGSV), balloon angioplasty (BA), stenting, and atherectomy for advanced PA disease in patients with CLTI using a national database.

Methods: We used VQI data for infrainguinal CLTI (2016-2023). We queried four cohorts: bypass with SSGSV, BA, stenting, and atherectomy. Bypasses included those with inflow of superficial femoral artery or above-knee PA and outflow of below-knee PA or tibioperoneal trunk. ET cohorts included TASC-C and TASC-D isolated PA interventions. BA and stenting groups included respective plain and drug-eluting devices. The primary outcomes were amputation-free survival (AFS) and freedom from major adverse limb events (MALE) or death. MALE was defined as any major amputation (MA) and/or reintervention. Secondary outcomes included overall survival, limb salvage, freedom from reintervention, and freedom from MALE. All outcomes were analyzed within one-year. Kaplan-Meier estimates and Cox regression were used for the analysis.

Results: There were 5,290 limbs from 4,870 patients: 913 bypasses with SSGSV (17.3%), 1,423 BA (26.9%), 2,336 stenting (44.2%), and 618 atherectomy (11.7%). One-year AFS was 87.4%, 76.1%, 78.5%, and 81.0%, and MALE-free survival was 74.2%, 64.4%, 64.1%, and 66.8% in SSGSV, BA, stenting, and atherectomy cohorts, respectively (P <.001) (Fig I). After adjusting for confounders, BA and stenting were associated with increased hazards of MA/death compared to SSGSV (aHR=1.42, 95%CI=1.09-1.85; P=0.010 and aHR=1.47, 95%CI=1.14-1.88; P=0.003, respectively). Additionally, stenting was associated with increased hazards of MALE and MALE/death compared to SSGSV (aHR=1.27, 95%CI=1.03-1.56; P=0.022 and aHR=1.34, 95%CI=1.13-1.60; P=0.001, respectively) but BA and atherectomy were not (Table I). Analyses among ET cohorts were further adjusted for the lesion length, treatment length, TASC-C vs. TASC-D, and calcification degree. However, there were no significant differences observed across the ET subgroups (Table I).

Conclusions: In this real-world analysis, angioplasty, atherectomy and stenting were associated with increased risk of death, major amputation or MALE compared to SSGSV bypass. We conclude that bypass with vein should be considered the first-line of treatment in fit patients with CLTI due to isolated advanced popliteal artery disease. Further prospective studies are necessary to better clarify the optimal approaches to popliteal artery disease especially in poor surgical candidates.