Drug-Eluting Stents are Associated with Superior Mid-Term Outcomes for the Treatment of Infrainguinal Bypass Graft Stenoses

OBJECTIVE: We previously demonstrated that everolimus drug-eluting stents (eDES) have reasonable short-term patency for the treatment of infrainguinal bypass stenoses. The aim of this study was to compare mid-term outcomes of eDES, plain balloon angioplasty (PTA), percutaneous cutting balloon (PCB), and drug-coated balloon (DCB) interventions for failing infrainguinal bypasses. METHODS: We conducted a retrospective review of patients with infrainguinal bypass stenoses treated by endovascular intervention (08/2010-08/2021). The primary outcome was primary patency (PP). Secondary outcomes were primary-assisted patency (PAP), secondary patency (SP), limb salvage (LS), and mortality. Outcomes were compared by treatment using Kaplan-Meier curves with log-rank tests and Cox proportional hazards models adjusting for baseline differences between groups. RESULTS: 72 consecutive patients with 152 discrete infrainguinal bypass graft stenoses were identified. Mean age was 65.1±10.6 years, 55.6% were male, and 48.6% were Black. 81.9% of patients were originally treated for chronic limb-threatening ischemia, and 57.2% of distal anastomoses were to tibial or pedal targets. Of 152 lesions, 44.1% (n=67) were treated with PTA, 17.8% (n=27) with PCB, 20.4% (n=31) with DCB, and 17.8% (n=27) with eDES. Median follow-up was 28.5 months (IQR 11.5-51.9). There was no difference in bypass configuration, conduit choice, or stenosis location (proximal anastomosis, mid-bypass, distal anastomosis) between groups. At 24-months post-intervention, PP was significantly better for eDES (72.9%, 95% CI 49.8-85.6%), followed by PCB (55.9%, 95% CI 34.2-72.9), PTA (34.4%, 95% CI 21.7-47.4), and DCB (33.6%, 95% CI 14.5-53.9%) (P=0.03). PAP, LS, and mortality did not significantly differ between modalities (P\u3e0.05). After risk adjustment, eDES was associated with the lowest risk of PP loss (HR vs. PTA 0.15, 95% CI 0.05-0.47). CONCLUSION: eDES are associated with superior 24-month patency rates compared to other endovascular technologies, and should be considered a primary therapy modality for the treatment of infrainguinal bypass graft stenoses