Cardiovascular Journal of Africa: Vol 26 No 1 (January/February 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015 34 AFRICA
Comparison between superficial femoral artery stenting
and bypass surgery in severe lower-limb ischaemia:
a retrospective study
J Islam, JV Robbs
Abstract
Background: Symptomatic femoro-popliteal disease is treated
by bypass surgery or angioplasty with or without stenting.
The aim of this study was to compare the results of stenting
and bypass surgery with regard to limb salvage in patients
with severe leg ischaemia.
Methods: A total of 213 patients with femoro-popliteal
disease presenting with severe claudication or critical limb
ischaemia between January 2009 and December 2013 were
evaluated; 118 patients (139 limbs) had stents placed and 95
patients (104 limbs) had bypass surgery. Most (60%) present-
ed with critical limb ischaemia (rest pain 40%, tissue necrosis
20%), and the remainder with severe claudication. The treat-
ment groups had matching risk factors.
Results: The average age was 66 years and 73% were male.
Tissue necrosis was found in 26% of the stent group and 12%
of the bypass group (p = 0.009). In the stent group 26% had
adjunctive procedures, compared to 16% in the bypass group
( p = 0.138). During the one-year follow up, there were 30 stent
occlusions (22%) and 18 graft occlusions (17%) (p = 0.42).
There were 14 major amputations (10%) in the stent group,
and 13 (13%) in the bypass group (p = 0.68). Limb salvage rate
was 90% in the stent group, and 88% in the bypass group ( p =
0.68). There were no peri-operative deaths in the stent group,
but one in the bypass group (1%). One-year mortality rate was
equal (8%) in both groups (p = 1.00).
Conclusion: One-year outcome was comparable in both
groups with regard to mortality, stent or graft patency and
limb salvage rates.
Keywords: superficial femoral artery, stenting, bypass, severe leg
ischaemia
Submitted 8/9/14, accepted 27/11/14
Cardiovasc J Afr 2015; 26: 34–37
DOI: 10.5830/CVJA-2014-074
Symptomatic superficial femoral artery (SFA) disease presenting
either with severe claudication or critical limb ischaemia is
treated with bypass surgery and traditionally has been the ‘gold-
standard’ procedure. Surgical bypass using autogenous vein
or prosthetic grafts as a conduit is well accepted and there are
comparable patencies and limb salvage rates with either conduit.1
There have been considerable advances in the last two decades
in percutaneous endovascular technology for the treatment of
SFA disease. The techniques that have been developed include
percutaneous balloon angioplasty and stenting, with variable
results.2,3 Despite having three different options, namely surgical
bypass, balloon angioplasty and stenting, none is superior to the
other.
Although the five-year primary patency rate of femoro-
popliteal above-the-knee bypass with autogenous saphenous vein
is 70%, this method of treatment is invasive with long incisions
in the lower extremities and a peri-operative complication rate
of 12%.4 Vascular surgeons have become more experienced with
catheter-based technology and due to the minimal invasiveness
of the procedure, both patients and vascular surgeons are
increasingly attracted to endovascular procedures. Mwipatayi
et al.5 and Nguyen et al.6 found stenting resulted in equivalent
outcomes when compared to balloon angioplasty alone, but
Laird et al.7 found that self-expanding nitinol stents were
associated with better angiographic results and improved patency
compared with balloon angioplasty alone.
Randomised, controlled trials comparing bypass surgery and
balloon angioplasty alone generally showed similar outcomes in
terms of amputation-free survival but in the short term, surgery
was more expensive than angioplasty.8 Another study comparing
surgical bypass with balloon angioplasty and stenting showed
better primary patency for the stent group (67%) than the bypass
group (49%) and there were higher re-intervention rates in the
bypass group.9
Since there are conflicting data in the literature regarding
the success of different methods of treatment of SFA disease
and there is a lack of consensus guidelines on the optimum
management of SFA disease, the aim of this study was to
compare the results of stenting and surgical bypass in the local
environment with regard to limb salvage rates in patients with
severe leg ischaemia.
Methods
Patients with superficial femoral artery (femoro-popliteal)
disease presenting to a single practice, with severe claudication
(crippling), preventing themfromperforming their daily activities,
or critical limb ischaemia, admitted to Entabeni Hospital,
Durban, South Africa between January 2009 and December
2013 were culled from a prospectively maintained database. Two
Department of Vascular Surgery, Grey’s Hospital, Nelson R
Mandela School of Medicine, University of KwaZulu-Natal,
Pietermaritzburg, South Africa
J Islam, MB BS, DA (SA), FCS (SA), Cert Vasc Surg (SA),
MMedSci (UKZN),
University of KwaZulu-Natal, and Entabeni Hospital,
Durban, South Africa
JV Robbs, MB ChB, ChM, FCS (SA), FRCSEd, FRCPS (Glas)