38 / 68
CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 1, January/February 2015
36
AFRICA
managed by thrombectomy, angioplasty with or without stenting
(five), or redo bypass (nine). Four septic grafts were removed.
There were 14 major amputations (10%) in the stent group
and 13 (13%) in the bypass group (
p
=
0.68). The limb salvage
rate was 90% in the stent group and 88% in the bypass group (
p
=
0.68). There were no peri-operative (30-day) deaths in the stent
group, but one peri-operative death after discharge home due to
an unknown cause in the bypass group (1%). One-year mortality
rate was equal (8%) in both groups (
p
=
1.00), as shown in Table
5. The causes of late deaths were myocardial infarction (10) and
sepsis (two). In five patients the cause of death remained obscure.
Discussion
All of our patients treated by endovascular techniques received
a stent in addition to angioplasty. This is different from that
reported in the BASIL (Bypass versus Angioplasty in Severe
Ischaemia of the Leg) trial where patients in the endovascular
group underwent angioplasty alone.
8
During the same time
period we had another 30 patients, who had balloon angioplasty
done alone for the SFA disease, but we did not include them in
this study, as we feel that balloon angioplasty and stenting have
different results in terms of patency. This may differ from other
authors.
10
Stenting is appropriate for complex lesions and as a ‘bail-
out’ procedure after complications of balloon angioplasty, or
recoil after balloon dilatation, and the outcome with stenting
is superior to balloon angioplasty alone.
6,7,11
We did not give
preference to any specific stent, and a single stent was preferred
in order to cover the entire lesion; multiple stents were however
deployed if necessary.
In all cases, bare-metal, self-expanding nitinol stents were
used. It has been reported that long-term outcomes of SFA
intervention comparing endografts and bare-metal nitinol stents
were similar.
12
The average lesion length was 7.84 cm (range 4 to
20 cm) and the stent diameters ranged from 5 to 7 mm.
Eighty-six limbs (83%) had above-the-knee bypass, all using
prosthetic grafts. Below-the-knee bypass was done in 18 (17%); a
prosthetic graft was used in 14 of these and reversed saphenous
vein grafts were used in four patients.
Although in one study the five-year patency and
re-intervention rates were superior in above-the-knee bypass
with saphenous vein grafts,
13
other randomised, controlled trials
showed that the outcome in terms of patency and limb salvage
rates were comparable.
1,4
Below-the-knee bypass with vein grafts
is definitely superior to prosthetic grafts.
14
Lack of availability of
suitable veins precluded their use, and we were compelled to use
prosthetic grafts in most cases.
Out of 86 above-the-knee prosthetic bypasses, 11 had a major
amputation and of 18 below-the-knee bypasses, two resulted
in amputation. Though no patient with a vein graft had an
amputation, this was not statistically significant (
p
=
1.00).
The difference between stent and graft occlusion rates was not
statistically significant (22 vs 17%,
p
=
0.42), and the stent and
graft patency rates were similar in both groups: 109 (78%) in the
stent group and 86 (83%) in the bypass group (
p
=
0.42). There
was no difference in the major amputation rate between stents
and bypasses, with 14 amputations (10%) in the stent group and
13 (13%) in the bypass group (
p
=
0.68). Among the patients who
had amputation, 93% had presented with tissue necrosis in the
stent group, and 46% in the bypass group (
p
=
0.01). The limb
salvage rate was similar in both groups; 125 (90%) in the stent
group and 91 (88%) in the bypass group (
p
=
0.68).
One-year mortality rate was similar in both groups; 10 (8%)
in the stent group and eight (8%) in the bypass group (
p
=
1.00).
The causes of late deaths were similar to previous reports, being
mainly due to myocardial infarction. The current report was
limited to a one-year follow up. This might have been responsible
for the higher stent and graft patency, or limb salvage rates in
comparison to other series.
9,15
No patients were lost to follow up.
There are not many publications comparing femoral artery
stenting and bypass surgery, and the assessment of patency and
the overall results of different treatment modalities is somewhat
problematic, as study designs vary considerably.
16-19
In our series,
Table 2. Demography and risk factors
Stent (
n
=
118)
n
(%)
Bypass (
n
=
95)
n
(%)
p
-value
Age (years)
67
65
0.08
Males
81 (69)
75 (79)
0.11
Hypertension
85 (72)
63 (66)
0.37
Diabetes
60 (51)
35 (37)
0.05
Smoking
65 (55)
51 (54)
0.89
IHD
45 (38)
30 (32)
0.38
CVD
12 (10)
12 (13)
0.66
Renal failure
9 (8)
6 (6)
0.79
IHD: ischaemic heart disease, CVD: cerebrovascular disease.
Percentage rounded to the nearest integer.
Table 3. TASC II lesions
TASC II
Number (%) Stent (%) Bypass (%)
A
46 (19)
43 (93)
3 (7)
B
97 (40)
72 (74)
25 (26)
C
24 (10)
13 (54)
11 (46)
D
76 (31)
11 (14)
65 (86)
Total
243
139
104
TASC: Trans-Atlantic Inter-Society Consensus.
Percentage rounded to the nearest integer.
Table 4. Adjunctive procedures
Stent
Bypass
p
-value
Popliteal-tibial angioplasty
22
0
Iliac angioplasty/stenting
5
15
CFA patch
4
0
Total
31 (26%)
15 (16%)
0.13
CFA: common femoral artery.
Table 5. Outcomes after one year
Stent (
n
=
139)
n
(%)
Bypass (
n
=
104)
n
(%)
p
-value
Stent/graft occlusion
30 (22)
18 (17)
0.42
Major amputation
14 (10)
13 (13)
0.68
Death
10 (8)
8 (8)
1.00
Stent/graft patency rate
109 (78)
86 (83)
0.42
Limb salvage
125 (90)
91 (88)
0.68
Percentage rounded to the nearest integer.