Evaluating the management of chronic limb threatening ischaemia due to femoro-popliteal disease

Meecham, Lewis ORCID: 0000-0003-4698-7333 (2023). Evaluating the management of chronic limb threatening ischaemia due to femoro-popliteal disease. University of Birmingham. M.D.

Preview

Meecham2023MD.pdf
Text - Accepted Version
Available under License All rights reserved.
Download (8MB) | Preview

Abstract

Introduction

Peripheral arterial disease is an increasing global health problem, particularly in low and middle-income countries. Traditionally the primary cause was smoking, as smoking rates decrease and life expectancy increases, Diabetes Mellitus and renal failure are becoming more common causes. Little evidence exists to guide the treatment of chronic limb threatening ischaemia (CLTI). Best medical therapy (antiplatelet, statin, hypertensive therapy and smoking cessation) is essential to reduce the risk of secondary cardiovascular events. When it comes to revascularisation, there are now two multicentre randomised controlled trials comparing bypass surgery or endovascular intervention for infra-inguinal peripheral arterial disease; the BASIL trial and BEST-CLI. Both have reported superior outcomes for vein bypass compared to endovascular intervention and advocate a bypass surgery first approach in infra-inguinal CLTI. Bypass with synthetic conduit (PTFE or Dacron) should only be offered as a last resort. The aim of this thesis is to analyse the current trends in revascularising patients with femoro-popliteal induced CLTI, and whether these treatments have resulted in better outcomes for patients.

Methods

The BASIL trial cohort was used as a baseline for comparison. The contemporary series of patients were gathered from one large University Hospital trust (HEFT). Patients undergoing primary femoro-popliteal revascularisation (bypass surgery or angioplasty) between 2009-2014 were included. Statistical analysis was performed using SAS v9.5 and SPSS v24.

Results

Re-analysis of the cohort of patients in the BASIL trial undergoing femoro-popliteal intervention (approx. 75%) yielded very similar results to that of the whole trial cohort. Those patients who underwent secondary bypass surgery after a failed endovascular intervention did significantly worse than those who underwent primary bypass, indicating that endovascular intervention is not the free shot that is so often claimed. In terms of contemporary practise, those patients being treated either by FP endo or Bypass surgery have far worse outcomes now compared to that seen in the BASIL trial (AFS and OS) despite better technical success and better rates of medical therapy. Finally, the new Global Limb Anatomy Stage System (GLASS) accurately predicts technical success of endovascular intervention and likelihood of poorer limb outcomes as grade increases in this contemporary cohort.

Conclusion

Open surgical bypass for femoro-popliteal disease was superior to endovascular intervention when BASIL was conducted. Contemporary outcomes after femoropopliteal revascularisation, with an endovascular first strategy, are worse than that observed in the BASIL trial.

Type of Work:

Thesis (Doctorates > M.D.)

Award Type:

Doctorates > M.D.

Supervisor(s):