Endovascular bypass as a strategy for long femoropopliteal lesions

INTRODUCTION: Endovascular treatment has become the predominant treatment modality for femoropopliteal lesions. In longer and more complex lesions advanced technology is often required to improve results, with the endovascular bypass being one of them.

EVIDENCE ACQUISITION: A systematic review of the literature was performed to determine the clinical and technical outcomes of the latest generation endoprosthesis, with heparin bioactive surface and contoured proximal edge.

EVIDENCE SYNTHESIS: 13 articles were enrolled: 3 randomized controlled trials, 4 prospective multicenter trials and 6 retrospective studies. The VIASTAR trial showed that the endoprosthesis has a better two-year primary patency compared to bare metal stenting, especially in long lesions (62% vs. 27%, P=0.004). The SUPERB trial showed that the endoprosthesis had similar results compared to bypass surgery, albeit with less complications (31% vs. 55%, P=0.048). The RELINE study showed that treatment with an endoprosthesis had a better one-year primary patency compared to balloon angioplasty for in-stent restenosis (75% vs. 28%, P<0.001). In the cohort studies one-year patency rates ranged from 61% to 86% for primary patency, from 65% to 92% for primary assisted patency, and from 83% to 95% for secondary patency.

CONCLUSIONS: For long femoropopliteal lesions, the heparin-bonded endoprosthesis is related to better outcomes compared to bare nitinol stents, and comparable outcomes as with the femoropopliteal bypass, but with less complications. There is a wide range in primary patency rates, with consistent high secondary patency rates. The endovascular bypass can be considered an appropriate strategy in these patients.