Patterns of Index Endovascular Compared With Surgical Revascularization for Femoropopliteal Disease in Patients With Claudication Using Medicare-linked Data

OBJECTIVE: To compare outcomes of endovascular versus open infrainguinal bypass in patients with claudication. SUMMARY OF BACKGROUND DATA: PAD research has focused largely on CLTI, yet 20% of patients present with claudication and may not improve with medical therapy alone. Durability of endovascular intervention remains uncertain. METHODS: Patients undergoing bypass for femoropopliteal disease were propensity matched to endovascular procedures using demographics, cardiovascular comorbidities, and center volume quartiles. Primary outcomes (CLTI, MALE) were ascertained via VISION-Medicare linkage. Secondary outcomes included reintervention and mortality. Kaplan-Meier and Cox models quantified associations between intervention and outcome. Sensitivity analysis used inverse probability weighting and Fine-Gray models. RESULTS: Seven hundred twenty open bypass procedures were matched to 3259 endovascular procedures (median follow-up 2.8 y, IQR 1.6-4.4). Median age was 72 versus 70 years (open vs. endovascular, P<0.001); most patients were non-Hispanic White (91.1% vs. 85.6%, P<0.001) and male (74.4% vs. 61.3%, P<0.001). MALE rates were higher with endovascular intervention at 1 year (33.4% vs. 37.3%, P=0.015), but not at 3 (49.5% vs. 49.1%, P=0.172), or 5 years (57.0% vs. 59.1%, P=0.149). CLTI progression, reintervention rates, and mortality were similar at 5 years. Endovascular intervention was not associated with MALE (HR 1.13, 95% CI: 0.97-1.32), CLTI progression (HR 0.90, 95% CI: 0.72-1.13), reintervention (HR 1.13, 95% CI: 0.97-1.32), or mortality (HR 0.86, 95% CI: 0.66-1.12). CONCLUSION: Open bypass and endovascular intervention demonstrated similar long-term MALE and progression to CLTI through 5 years, suggesting endovascular intervention may offer comparable outcomes in appropriately selected patients with claudication.