Endovascular Therapy, Open Surgical Bypass, and Conduit Types for Index Treatment of Claudication

Importance Despite advances in infrainguinal revascularization and established guidelines, direct comparisons between endovascular and open surgical strategies remain limited due to challenges in trial enrollment, anatomical variability, and lack of long-term follow-up. Objective To compare the outcomes of index endovascular procedures vs open surgical bypass among patients with peripheral arterial disease with claudication. Design, Setting, and Participants This retrospective cohort study, spanning from January 2007 to October 2024, enrolled participants with femoropopliteal peripheral arterial disease who underwent nonemergent index interventions for the indication of claudication into the multicenter national registry Vascular Quality Initiative. Exposures Category of revascularization procedure and type of conduit. Main Outcomes and Measures The primary outcome was major amputation above the ankle at 1 year. Results In total, 22 328 patients were included (mean [SD] age, 67.7 [10.3] years for the entire cohort; 64.4 [10.0] years for 4474 patients in the open surgical bypass group, and 68.6 [10.2] years for 17 854 patients in the endovascular procedures group). Patients had a median (IQR) follow-up duration of 1.0 (0.9-1.4) years (maximum, 8.3 years). Most patients were male (open 3334 [74.5%] vs endovascular 10 938 [61.3%]; P < .001), and both groups had similar obesity rates (1589 [35.6%] for open vs 6284 [35.2%] for endovascular; P = .14). Cardiovascular comorbidities were prevalent in both groups (eg, hypertension, 3693 [82.5%] for open and 15 750 [88.2%] for endovascular). Endovascular interventions were associated with a significantly lower major amputation risk at 1 year (hazard ratio [HR], 0.67 [95% CI, 0.48-0.96]; P = .03) but also associated with higher risk of death at 1 year (HR, 2.09 [95% CI, 1.97-2.23]; P < .001) that was unchanged after propensity matching. Among open bypass procedures, prosthetic conduits were not associated with higher major amputation risk (HR, 1.66 [95% CI, 0.91-3.03]; P = .10) and had equivalent patency (HR, 0.96 [95% CI, 0.90-1.02]; P = .23) at 1 year compared with great saphenous vein (GSV) conduits. Among single segment GSV conduits, reversed GSV conduits were associated with the lowest major amputation risk (HR, 0.40 [95% CI, 0.20-0.83]; P = .01) at 1 year compared with in situ and transposed GSV conduits (likelihood ratio test, P = .002). Among prosthetic conduits, Dacron grafts were associated with higher major amputation risk than polytetrafluoroethylene grafts (HR, 4.78 [95% CI, 1.02-22.30] vs HR, 1.59 [95% CI, 1.15-2.20]; likelihood ratio test, P = .002). Conclusions and Relevance In this cohort study of 22 328 participants who underwent femoropopliteal index interventions for claudication, endovascular procedures were associated with lower rates of major amputation at 1 year compared with open surgical bypass approaches. The findings suggest that if an open approach is needed, reversed GSV conduits should be prioritized in surgical bypass.