Outcomes of interventions for recurrent disease after endoluminal intervention for superficial femoral artery disease.

BACKGROUND: Aggressive endoluminal therapy for superficial femoral artery (SFA) occlusive disease is commonplace, but the outcomes of current management of recurrent disease have not been well defined. This study examined the outcomes of endoluminal and open interventions for recurrent SFA disease.

METHODS: A database of patients undergoing endovascular treatment of the SFA between 1986 and 2008 was retrospectively queried, and those with recurrent disease were selected. Outcomes were determined by Kaplan-Meier survival analyses, and the Cox proportional hazard model was used for time-dependent variables.

RESULTS: Symptomatic SFA disease resulted in endovascular treatment in 735 limbs in 631 patients (64% male; average age, 67 years). The restenosis rate was 16% +/- 3% at 5 years. Restenosis developed in 222 patients, of whom 58 remained asymptomatic and 164 underwent repeat intervention comprising percutaneous transluminal angioplasty (PTA) in 59% and bypass in 41%. Bypass was used for critical ischemia (rest pain/tissue loss: 52% repeat PTA vs 75% bypass) and in more extensive recurrent disease (TransAtlantic Inter-Society Consensus [TASC] II C/D lesions: 42% repeat PTA vs 67% bypass). Primary and repeat PTA had mean +/- standard error of the mean equivalent cumulative patency (73% +/- 9% vs 73% +/- 3% at 5 years) and duration of symptom relief (66% +/- 3% vs 63% +/- 6%). Bypass had significantly superior outcomes for patency (93% +/- 8%) and symptom relief (81% +/- 8%), but morbidity was 28% vs 16% for PTA. Critical ischemia, TASC-II lesion (C/D), and one-vessel tibial runoff were significant predictors of failure in the repeat PTA group.

CONCLUSIONS: Reintervention is required in a minority of patients selected for SFA angioplasty. Bypass for recurrent disease is used more commonly for extensive disease and is associated with superior long-term outcomes but higher mortality. Bypass rather than repeat PTA may be the better strategy for progressive, complex recurrent disease.