Original article

Strategy-based revascularization for complex femoropopliteal disease: endovascular-first versus surgical bypass in contemporary practice

---

Abstract

Aim: To compare the outcomes of endovascular treatment (EVT) and surgical bypass (BP) for the management of complex femoropopliteal (FP) artery disease.

Methods: This retrospective single-centre cohort study included patients with Trans-Atlantic Inter-Society Consensus (TASC II) C–D lesions in the FP segment treated between 2018 and 2023. The patients were categorized into two groups according to treatment strategy: EVT and surgical BP. The primary outcome was primary patency at 12 and 24 months. Secondary outcomes included target lesion revascularization, amputation-free survival, major amputation, and procedural complications.

Results: A total of 168 patients were included, with 98 patients in the EVT group and 70 patients in the BP group. Patients in the BP group had significantly longer lesion lengths and a higher prevalence of chronic total occlusions. Kaplan–Meier analysis demonstrated significantly higher primary patency in the BP group compared with the EVT group at 12 months (86.9% vs 71.4%, log-rank p=0.018) and 24 months (78.1% vs 58.2%, log-rank p=0.009). Target lesion revascularization occurred in 7 patients (7.1%) in the EVT group and 4 patients (5.7%) in the BP group (RR=1.25; 95% CI 0.38–4.07). Major amputation occurred in 9 patients (9.2%) in the EVT group and 7 patients (10.0%) in the BP group (RR=0.92; 95% CI 0.36–2.35). In multivariable analysis, BP was independently associated with reduced risk of primary patency loss (HR=0.58; 95% CI 0.35–0.94; p = 0.028).

Conclusion: In patients with complex FP disease, BP was associated with higher mid-term primary patency compared with EVT, while limb-related outcomes remained comparable between strategies.

Keywords: angioplasty, disease progression, limb salvage, peripheral arterial disease, prostheses and implants