Bypass versus endovascular intervention for healing ischemic foot wounds secondary to tibial arterial disease

Abstract Objective Pedal (inframalleolar) bypass is a long-standing therapy for tibial arterial disease in patients with ischemic tissue loss. Endovascular tibial intervention is an appealing alternative with lower risks of perioperative mortality or complications. Our objective was to compare the effectiveness of these two treatment modalities with respect to patency and limb-related clinical outcomes. Methods We performed a retrospective chart review of patients presenting between 2006 and 2013 with ischemic foot wounds and infrapopliteal arterial disease who underwent a revascularization procedure (either open surgical bypass to an inframalleolar target or endovascular tibial intervention). Data were collected on baseline demographics and comorbidities, procedural details, and postprocedure outcomes. The primary outcome was successful healing of the index wound, with mortality, major amputation, and patency assessed as secondary outcomes. Results We identified 417 patients who met our eligibility criteria; 105 underwent surgical bypass and 312 underwent endovascular intervention, with mean follow-up of 25.0 and 20.2 months, respectively ( P  = .08). The endovascular patients were older at baseline ( P  = .009), with higher rates of hyperlipidemia ( P  = .02), prior cerebrovascular accidents ( P  = .04), and smoking history ( P  = .04). Within 30 days postoperatively, there was no difference in mortality ( P  = .31), but bypass patients had longer hospital length of stay ( P P P  = .03) and wound complications ( P P  = .02). At 1 year, survival was higher after bypass (86.2% vs 70.4%; P P  = .42). Primary patency (53.1% vs 38.2%; P  = .002) and primary assisted patency (76.6% vs 51.7%; P P  = .13). Conclusions Endovascular tibial intervention is associated with poorer primary patency but similar secondary patency and wound healing rates compared with the "gold standard" of surgical bypass to a pedal target. In patients with tibial arterial disease, endovascular intervention should be considered a lower risk alternative to pedal bypass that provides similar clinical outcomes.