Stenting vs above knee polytetrafluoroethylene bypass for TransAtlantic Inter-Society Consensus-II C and D superficial femoral artery disease

ObjectivesTransAtlantic Society Consensus (TASC)-II recommends bypass for TASC D and low-risk patients with TASC C lesions but does not specify graft types. Percutaneous balloon angioplasty/stenting (PTA/S) and above knee femoropopliteal bypass (AK-FPB) using polytetrafluoroethylene (PTFE) for these lesions were compared to determine if graft type should be part of the TASC-II recommendations for the treatment of TASC C lesions.MethodsConsecutive patients who underwent AK-FPB with PTFE, or PTA/S for TASC-II C (PTA/S-C) or D (PTA/S-D) SFA lesions between June 2001 and April 2007 were retrospectively analyzed. The primary end points were primary, assisted-primary, and secondary patency rates.ResultsIn 127 patients (mean age, 68.7 ± 10.0 years; median, 68; range, 49-97), 139 limbs were treated (46 AK-FPB, 49 PTA/S-C, 44 PTA/S-D). The mean occlusion and stented lengths were 9.9 ± 3.8 and 24.3 ± 6.6 cm (median, 10 and 20 cm) in PTA/S-C, and 26.6 ± 5.5 and 30.0 ± 5.2 cm (median, 26 and 29 cm) in PTA/S-D. Technical success was 84% in PTA/S-D and 100% in other groups. Mean follow-up was 26.4 ± 18.0 months (median, 24). The 12- and 24-month primary patency was 83% ± 6% and 80% ± 7% for PTA/S-C; 54% ± 8% and 28% ± 12% for PTA/S-D; and 81% ± 6% and 75% ± 7% for AK-FPB (P < .001 PTA/S-D vs PTA/S-C and AK-FPB); assisted-primary patency was 95% ± 3% and 95% ± 3% for PTA/S-C, 62% ± 8% and 49% ± 10% for PTA/S-D, and 81% ± 6% and 75% ± 7% for AK-FPB (P < .001, PTA/S-C vs PTA/S-D; P = .003, PTA/S-C vs AK-FPB; and P = .03, PTA/S-D vs AK-FPB). Secondary patency was 98% ± 3% and 98% ± 3% for PTA/S-C; 72 % ± 7% and 54% ± 11% for PTA/S-D, and 81% ± 6% and 78% ± 7% for AK-FPB. Secondary patency was significantly better in PTA/S-C than AK-FPB (P = .003) and PTA/S-D groups (P < .001). The difference was marginally better in AK-FPB than in PTA/S-D (P = .064).ConclusionsPTA/S for TASC-II C lesions has a superior midterm patency than AK-FPB using PTFE, and AK-FPB with PTFE has better primary and assisted-primary patency than PTA/S-D. The TASC-II recommendations should be modified to recommend treatment of SFA TASC-II C lesions by PTA/S rather than PTFE bypass for all patients. PTA/S of TASC-II D lesions should only be considered in high-risk patients who cannot tolerate a bypass procedure using PTFE.