Abstract No. 42 Perioperative Events Following Open versus Endovascular Revascularization for Chronic Limb-Threatening Ischemia: An NSQIP Analysis

The Best Endovascular Versus Best Surgical Therapy in Patients With Critical Limb Ischemia (BEST-CLI) trial reported superiority of surgical bypass compared with endovascular intervention for the treatment of chronic limb-threatening ischemia (CLTI). Herein, we analyzed perioperative (30 day) outcomes from the National Surgical Quality Improvement Project (NSQIP) in patients who received intervention for CLTI. The NSQIP-Vascular targeted database was queried from 2014 to 2019, contemporaneous with BEST-CLI, for patients receiving either surgical bypass or endovascular intervention for CLTI. The cohorts were composed of (1) those who underwent bypass using saphenous vein, (2) those in whom an alternative conduit (e.g., prosthetic, spliced vein) was utilized, and (3) endovascular intervention. Inverse propensity weighting with regression adjustment was conducted to assess differences in 30-day outcomes including perioperative death (POD, death within 30 days), major amputation, major adverse limb events (MALE, major reintervention and/or amputation), composite MALE or POD, and major adverse cardiovascular events (MACE, myocardial infarction, or stroke). These results were depicted as average treatment effects (ATE) and their corresponding p-values. A total of 6,780 (43.3%) patients underwent surgical bypass with saphenous vein, 4,201 (32.1%) patients underwent surgical bypass with alternative conduit, and 8,887 (56.7%) patients underwent endovascular intervention. Compared to surgical bypass with GSV, the ATE of endovascular intervention was higher for major amputation (ATE: 0.014; p=0.002), higher for MALE (ATE: 0.017; p=0.004), similar for MALE or POD (ATE: 0.011; p=0.11), similar for mortality (ATE: -0.006; p=0.07), similar for major reintervention (ATE: 0.001; p=0.81), and lower for MACE (ATE: -0.019; p< 0.001). Compared to surgical bypass with an alternative conduit, the ATE of endovascular intervention was similar for major amputation (ATE: 0.002; p=0.763), MALE (ATE: 0.006; p=0.34), MALE or POD (ATE: 0.001; p=0.93), mortality (ATE: -0.008; p=0.053), major reintervention (ATE: -0.004; p=0.50), and lower for MACE (ATE: -0.021; p< 0.001). These data demonstrate a higher rate of early amputation and MALE among those who underwent endovascular intervention versus surgical bypass with saphenous vein. Conversely, surgical bypass with any conduit type was associated with a higher rate of MACE within 30 days. These data highlight the importance of patient selection to optimize outcomes in CLTI patients.