Outcomes of bypass versus endovascular procedures in long chronic total occlusions of the superficial femoral artery – a 10-year cohort study

BACKGROUND: With the development of advanced endovascular technologies to treat chronic total occlusions of the superficial femoral artery (SFA-CTO), endovascular procedures have become more common, with supragenicular femoropopliteal artery bypasses reserved for a subset of patients. We aim to compare outcomes of long SFA-CTOs treated with surgical bypass versus endovascular procedures. METHODS: Single-centre retrospective cohort study in a tertiary centre including all patients with SFA-CTOs (femoropopliteal GLASS grade 4/TASC-II D) submitted to a supragenicular femoropopliteal artery bypass (OR group) or endovascular revascularisation procedure (EVT group) from February 2015 to January 2025. Patients undergoing revascularisation of other anatomical sectors were excluded. Baseline characteristics, peri-procedural and follow-up data were obtained. The primary endpoint is major adverse limb events (MALE). The secondary endpoints are MALE-free survival, reintervention rates, amputation rates, and mortality rates. RESULTS: 119 patients were included (71 in the OR group vs. 48 in the EVT group). Eighty-six per cent (N=61N=61) of the OR group received a prosthetic conduit. Median age was 68 years (IQR 63-74), and 75 patients (63%63%) had chronic limb-threatening ischemia. The median hospital stay was shorter in the EVT group (2 vs. 9 days; p<.001p<.001). Other characteristics, such as age, risk factors, and Leriche-Fontaine classification, did not differ between groups. During a median follow-up period of 51 months (IQR 26-78), MALE were higher in the OR group (44%44%) vs. 25%25% - p=.038p=.038) despite no significant differences in MALE-free survival. A higher rate of reintervention was also found in the OR group (39%39% vs. 21%21% p=.033p=.033). There were no significant differences in amputation or mortality rates between groups. CONCLUSION: Patients with long SFA-CTOs had similar rates of limb salvage and mortality after bypass or endovascular interventions. Despite similar comorbidity burdens in both groups, MALE and reintervention rates were higher after bypass, suggesting an endovascular-first approach.