The Impact of Femoropopliteal Chronic Total Occlusions on Comparative Outcomes of Endovascular Resvascularization and Bypass for Intermittent Claudication

Based on current anatomic classifications and guidelines, endovascular revascularization is recommended for short femoropopliteal chronic total occlusions (CTOs) and increasingly used to treat longer CTOs. However, in patients with claudication secondary to femoropopliteal disease, the impact of the presence and extent of femoropopliteal CTOs on the comparative long-term efficacy of lower extremity bypass and endovascular revascularization is not known. We used CPT billing codes to identify lower extremity endovascular revascularization and bypasses performed by a single group between 2013 and 2023. Chart and angiogram review then identified for inclusion procedures that were performed for claudication due to femoropopliteal disease, had complete angiograms available, and had long-term follow-up. Only the first procedure performed per limb was included. Long-term outcomes were compared with Kaplan-Meier curves. Of 1091 total revascularizations over the study period, 127 met inclusion criteria. A total of 43 (33.9%) had endovascular revascularization of stenotic lesions (mean length = 6.6 cm), 40 (31.5%) had endovascular revascularization of a CTO (mean occlusion length = 11.1 cm), and 44 (34.6%) underwent lower extremity bypass (mean occlusion length = 18.0 cm). There were no significant differences in demographics or comorbidities between groups. Amongst endovascular revascularizations, 54.2% were bare metal stent, 12.0% were drug eluting balloon/stent, and 33.7% were plain balloon angioplasty. Bypasses included 21 suprageniculate and 23 infrageniculate targets and were performed with autogenous conduit in 32 (73.0%). There were no differences in peri-procedural complications between groups. At a median follow-up of 630 days, 3-year primary patency was significantly higher for endovascular revascularization of stenoses (80.3%) in comparison with endovascular revascularization of CTOs (50.4%) or bypass (59.2%, log-rank P = .018, Fig 1). Three-year freedom from major adverse limb events (MALE) was significantly higher for endovascular revascularization of stenoses (89.0%) in comparison to endovascular revascularization of CTO (69.6%) or open bypass (55.1%, log-rank P = .015, Fig 2). Patency and MALE were not different after revascularization of short (<5 cm) vs long CTOs (≥5 cm). In patients treated for intermittent claudication, endovascular treatment of stenotic lesions was associated with superior long-term outcomes in comparison with endovascular treatment of CTOs and lower extremity bypass. Short and long CTOs had equivalent long-term outcomes. The detrimental impact of short CTOs on long-term outcomes of revascularization in patients with claudication may be underestimated by current classifications and guidelines. Although broader validation is required, these results indicate that the presence of any femoropopliteal CTO heavily impacts revascularization outcomes and should influence treatment decisions for claudicants.