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Meta-Analysis
. 2017 Apr 3;4(4):CD002000.
doi: 10.1002/14651858.CD002000.pub3.

Bypass surgery for chronic lower limb ischaemia

George A Antoniou  1 , George S Georgiadis  2 , Stavros A Antoniou  3 , Ragai R Makar  4 , Jonathan D Smout  4 , Francesco Torella  4
Affiliations
Meta-Analysis

Bypass surgery for chronic lower limb ischaemia

George A Antoniou et al. Cochrane Database Syst Rev. .

Abstract

Background: Bypass surgery is one of the mainstay treatments for patients with critical lower limb ischaemia (CLI). This is the second update of the review first published in 2000.

Objectives: To assess the effects of bypass surgery in patients with chronic lower limb ischaemia.

Search methods: For this update, the Cochrane Vascular Group searched its trials register (last searched October 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (last searched Issue 9, 2016).

Selection criteria: We selected randomised controlled trials of bypass surgery versus control or any other treatment. The primary outcome parameters were defined as early postoperative non-thrombotic complications, procedural mortality, clinical improvement, amputation, primary patency, and mortality within follow-up.

Data collection and analysis: For the update, two review authors extracted data and assessed trial quality. We analysed data using odds ratio (OR) and 95% confidence intervals (CIs). We applied fixed-effect or random-effects models.

Main results: We selected 11 trials reporting a total of 1486 participants. Six trials compared bypass surgery with percutaneous transluminal angioplasty (PTA), and one each with remote endarterectomy, thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. The quality of the evidence for the most important outcomes of bypass surgery versus PTA was high except for clinical improvement and primary patency. We judged the quality of evidence for clinical improvement to be low, due to heterogeneity between the studies and the fact that this was a subjective outcome assessment and, therefore, at risk of detection bias. We judged the quality of evidence for primary patency to be moderate due heterogeneity between the studies. For the remaining comparisons, the evidence was limited. For several outcomes, the CIs were wide.Comparing bypass surgery with PTA revealed a possible increase in early postinterventional non-thrombotic complications (OR 1.29, 95% CI 0.96 to 1.73; six studies; 1015 participants) with bypass surgery, but bypass surgery was associated with higher technical success rates (OR 2.26, 95% CI 1.49 to 3.44; five studies; 913 participants). Analyses by different clinical severity of disease (intermittent claudication (IC) or CLI) revealed that peri-interventional complications occurred more frequently in participants with CLI undergoing bypass surgery than PTA (OR 1.57, 95% CI 1.09 to 2.24). No differences in periprocedural mortality were identified (OR 1.67, 95% CI 0.66 to 4.19; five studies; 913 participants). The primary patency rate at one year was higher after bypass surgery than after PTA (OR 1.94, 95% CI 1.20 to 3.14; four studies; 300 participants), but this difference was not shown at four years (OR 1.15, 95% CI 0.74 to 1.78; two studies; 363 participants). No differences in clinical improvement (OR 0.65, 95% CI 0.03 to 14.52; two studies; 154 participants), amputation rates (OR 1.24, 95% CI 0.82 to 1.87; five studies; 752 participants), reintervention rates (OR 0.76, 95% CI 0.42 to 1.37; three studies; 256 participants), or mortality within the follow-up period (OR 0.94, 95% CI 0.71 to 1.25; five studies; 961 participants) between surgical and endovascular treatment were identified. No differences in subjective outcome parameters, indicated by quality of life and physical and psychosocial well-being, were reported. The hospital stay for the index procedure was reported to be longer in participants undergoing bypass surgery than in those treated with PTA.In the single study (116 participants) comparing bypass surgery with remote endarterectomy of the superficial femoral artery, the frequency of early postinterventional non-thrombotic complications was similar in the treatment groups (OR 1.11, 95% CI 0.53 to 2.34). No mortality within 30 days of the index treatment or during stay in hospital in either group was recorded. No differences were identified in patency (OR 1.66, 95% CI 0.79 to 3.46), amputation (OR 1.70, 95% CI 0.27 to 10.58), and mortality rates within the follow-up period (OR 1.66, 95% CI 0.61 to 4.48). Information regarding clinical improvement was unavailable.No differences in major complications (OR 0.66, 95% CI 0.34 to 1.31) or mortality (OR 2.09, 95% CI 0.67 to 6.44) within 30 days of treatment between surgery and thrombolysis (one study, 237 participants) for chronic lower limb ischaemia were identified. The amputation rate was lower after bypass surgery (OR 0.10, 95% CI 0.01 to 0.80). No differences in late mortality were found (OR 1.56, 95% CI 0.71 to 3.44). No data regarding patency rates and clinical improvement were reported.Technical success resulting in blood flow restoration was higher after bypass surgery than thromboendarterectomy for aorto-iliac occlusive disease (one study, 43 participants) (OR 0.01, 95% CI 0 to 0.17). The periprocedural mortality (OR 0.33, 95% CI 0.01 to 8.65), follow-up mortality (OR 3.29, 95% CI 0.13 to 85.44), and amputation rates (OR 0.47, 95% CI 0.08 to 2.91) did not differ between treatments. Clinical improvement and patency rates were not reported.Comparing surgery and exercise (one study, 75 participants) did not identify differences in early postinterventional complications (OR 7.45, 95% CI 0.40 to 137.76) and mortality (OR 1.55, 95% CI 0.06 to 39.31). The remaining primary outcomes were not reported. There was no difference in maximal walking time between exercise and surgery (1.66 min, 95% CI -1.23 to 4.55).Regarding comparisons of bypass surgery with spinal cord stimulation for CLI, there was no difference in amputation rates after 12 months of follow-up (OR 4.00, 95% CI 0.25 to 63.95; one study, 12 participants). The remaining primary outcome parameters were not reported.

Authors' conclusions: There is limited high quality evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to optimal medical treatment. Our analysis has shown that PTA is associated with decreased peri-interventional complications in participants treated for CLI and shorter hospital stay compared with bypass surgery. Surgical treatment seems to confer improved patency rates up to one year. Endovascular treatment may be advisable in patients with significant comorbidity, rendering them high risk surgical candidates. No solid conclusions can be drawn regarding comparisons of bypass surgery with other treatments because of the paucity of available evidence. Further large trials evaluating the impact of anatomical location and extent of disease and clinical severity are required.

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Conflict of interest statement

GAA: none known GSG: none known SAA: received travel and accommodation expenses relating to the duties of the Journal and Publication Committee Members of the European Association for Endoscopic Surgery (EAES); travel, accommodation and congress participation expenses for the 21st International Congress of the EAES; travel and accommodation expenses for presentation of part of the Guidelines on the Closure of Abdominal Wall Incisions at the 36th International Congress of the European Hernia Society; travel and accommodation expenses for the development of the Guidelines on the Closure of Abdominal Wall Incisions RRM: none known JDS: received educational sponsorship (accommodation and course fee) from Cook Ltd for attendance at 2015 Leipzig Interventional Course (GORE Ltd). No personal payments were made. FT: received educational sponsorship (travel, accommodation and meeting‐related expenses) from Endologix Inc. This company produces medical devices. Such devices are not used for treatment of peripheral arterial disease and do not bear any direct relevance to the topic of this review.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of comparison: 1 Bypass surgery compared with angioplasty (PTA), outcome: 1.1 Early postoperative non‐thrombotic complications ‐ by symptoms at time of intervention.
5
5
Forest plot of comparison: 1 Bypass surgery compared with angioplasty (PTA), outcome: 1.6 Primary patency at 1 year.
6
6
Forest plot of comparison: 1 Bypass surgery compared with angioplasty (PTA), outcome: 1.7 Primary patency at 4 years ‐ by symptoms at time of intervention.
1.1
1.1. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 1 Early postoperative non‐thrombotic complications ‐ by symptoms at time of intervention.
1.2
1.2. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 2 Early postoperative non‐thrombotic complications ‐ by site of intervention.
1.3
1.3. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 3 Procedural mortality.
1.4
1.4. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 4 Clinical improvement.
1.5
1.5. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 5 Amputation ‐ by symptoms at time of intervention.
1.6
1.6. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 6 Primary patency at 1 year.
1.7
1.7. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 7 Primary patency at 4 years ‐ by symptoms at time of intervention.
1.8
1.8. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 8 Primary patency at 4 years ‐ by site of intervention.
1.9
1.9. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 9 Mortality within follow‐up ‐ by symptoms at time of intervention.
1.10
1.10. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 10 Technical success.
1.11
1.11. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 11 Assisted primary patency at 1 year.
1.12
1.12. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 12 Secondary patency at 1 year.
1.13
1.13. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 13 Secondary patency at 4 years.
1.14
1.14. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 14 Vessel or graft occlusion.
1.15
1.15. Analysis
Comparison 1 Bypass surgery compared with angioplasty (PTA), Outcome 15 Reinterventions.
2.1
2.1. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 1 Early postoperative non‐thrombotic complications.
2.2
2.2. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 2 Amputation.
2.3
2.3. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 3 Primary patency at 3 years.
2.4
2.4. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 4 Mortality within follow‐up.
2.5
2.5. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 5 Technical success.
2.6
2.6. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 6 Assisted primary patency at 3 years.
2.7
2.7. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 7 Secondary patency at 3 years.
2.8
2.8. Analysis
Comparison 2 Bypass surgery compared with remote endarterectomy, Outcome 8 Vessel or graft occlusion.
3.1
3.1. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 1 Early postoperative non‐thrombotic complications ‐ by site of intervention.
3.2
3.2. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 2 Procedural mortality ‐ by site of intervention.
3.3
3.3. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 3 Amputation ‐ by symptoms at time of intervention.
3.4
3.4. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 4 Amputation ‐ by site of intervention.
3.5
3.5. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 5 Mortality within follow‐up ‐ by symptoms at time of intervention.
3.6
3.6. Analysis
Comparison 3 Bypass surgery compared with thrombolysis, Outcome 6 Mortality within follow‐up ‐ by site of intervention.
4.1
4.1. Analysis
Comparison 4 Bypass surgery compared with thromboendarterectomy (TE), Outcome 1 Procedural mortality.
4.2
4.2. Analysis
Comparison 4 Bypass surgery compared with thromboendarterectomy (TE), Outcome 2 Amputation.
4.3
4.3. Analysis
Comparison 4 Bypass surgery compared with thromboendarterectomy (TE), Outcome 3 Mortality within follow‐up.
4.4
4.4. Analysis
Comparison 4 Bypass surgery compared with thromboendarterectomy (TE), Outcome 4 Technical success.
5.1
5.1. Analysis
Comparison 5 Bypass surgery compared with exercise, Outcome 1 Early postoperative non‐thrombotic complications.
5.2
5.2. Analysis
Comparison 5 Bypass surgery compared with exercise, Outcome 2 Procedural mortality.
5.3
5.3. Analysis
Comparison 5 Bypass surgery compared with exercise, Outcome 3 Mortality within follow‐up.
5.4
5.4. Analysis
Comparison 5 Bypass surgery compared with exercise, Outcome 4 Reintervention within follow‐up.
5.5
5.5. Analysis
Comparison 5 Bypass surgery compared with exercise, Outcome 5 Maximal walking time (minutes).
6.1
6.1. Analysis
Comparison 6 Bypass surgery compared with spinal cord stimulation (SCS), Outcome 1 Therapeutic success: poor result of intervention.
6.2
6.2. Analysis
Comparison 6 Bypass surgery compared with spinal cord stimulation (SCS), Outcome 2 Amputation.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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ABC 2010 {published data only}
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CLEVER study {published data only}
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de Donato 2002 {published data only}
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Devine 2004 {published data only}
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Djoric 2011 {published data only}
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Gelin 2001 {published data only}
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IRONIC Trial {published data only}
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Jensen 2007 {published data only}
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Mohammadi 2007 {published data only}
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Panneton 2004 {published data only}
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PROOF 2007 {published data only}
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Stanisic 2009 {published data only}
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Taft 2004 {published data only}
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Tiek 2009 {published data only}
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References to ongoing studies

BASIL 2 {published data only}
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BEST‐CLI trial {published data only}
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FINNPTX {published data only}
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ISRCTN18315574 {published data only}
    1. ISRCTN18315574. Minimal invasive balloon expansion versus bypass operation to treat complicated occlusions and stenoses of the femoral and popliteal arteries. www.isrctn.com/ISRCTN18315574 (accessed October 2016).
NCT01171703 {published data only}
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NCT02580084 {published data only}
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References to other published versions of this review

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