Contemporary systematic review and meta-analysis of outcomes associated with femoropopliteal above-the-knee nonautologous surgical bypass.

Abstract

Although endovascular therapy is increasingly used for femoropopliteal disease, surgical bypass remains an alternative for long-segment or heavily calcified lesions. However, contemporary outcomes for nonautologous conduits are not well established. This systematic review and meta-analysis provides a modern benchmark for outcomes associated with above-the-knee (ATK) femoropopliteal prosthetic bypass. A systematic search was conducted, leveraging a previously published search strategy while adopting a broader patient population and inclusive of relevant records published through January 2023. Included studies reported a minimum of 1 year of follow-up of primary or secondary patency, mortality, or limb salvage rates for patients who underwent femoropopliteal ATK revascularization via nonautologous surgical bypass. Risk of bias and quality of evidence assessments were conducted for each study and outcome. A pooled meta-analysis was performed using a random effects model for all outcomes at 6, 12, 24, and 36 months based on available reporting. Extensive subgroup analyses were conducted for 12-month outcomes, including stratification of records by type of prosthetic conduit, outcome definition, period of data collection, disease severity, underlying bias, and study design. The final sample included 16 records reporting on a total of 2083 patients and 2118 limbs. The pooled 6-, 12-, 24-, and 36-month overall event rates were 0.88 (95% confidence interval [CI], 0.85-0.90), 0.80 (95% CI, 0.77-0.82), 0.69 (95% CI, 0.65-0.72), and 0.61 (95% CI, 0.57-0.65) for primary patency; 0.92 (95% CI, 0.88-0.95), 0.86 (95% CI, 0.82-0.89), 0.79 (95% CI, 0.71-0.84), and 0.68 (95% CI, 0.56-0.78) for secondary patency; and 0.07 (95% CI, 0.02-0.14), 0.09 (95% CI, 0.06-0.13), 0.13 (95% CI, 0.10-0.17), and 0.24 (95% CI, 0.13-0.40) for mortality, respectively. Based on available data, only 12- and 24-month pooled estimates were derived for limb salvage, with resulting event rates of 0.97 (95% CI, 0.91-1.00) and 0.98 (95% CI, 0.66-1.00), respectively. Primary patency was generally more favorable for records adopting a Society for Vascular Surgery-oriented definition of primary patency, meaning freedom from flow-restoring or maintenance interventions. The 12-month pooled estimates for subgroup analyses stratified by type of prosthetic conduit were comparable for polytetrafluorethylene and Dacron across all outcomes. Additional details of subgroup analyses explored are discussed. The current analysis provides a comprehensive perspective on contemporary outcomes of nonautologous ATK femoropopliteal surgical bypass. In the management of long femoral-popliteal lesions in patients lacking a suitable greater saphenous vein conduit, the anticipated results of an endovascular approach must be compared with those included herein for prosthetic femoral-popliteal bypass. These data, with reporting of ≤36 months of follow-up, should be weighed for treatment decision-making.