Intervention Review

Bypass surgery for chronic lower limb ischaemia

  1. Freya Fowkes1,*,
  2. Gillian C Leng2

Editorial Group: Cochrane Peripheral Vascular Diseases Group

Published Online: 23 APR 2008

Assessed as up-to-date: 12 DEC 2007

DOI: 10.1002/14651858.CD002000.pub2


How to Cite

Fowkes F, Leng GC. Bypass surgery for chronic lower limb ischaemia. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002000. DOI: 10.1002/14651858.CD002000.pub2.

Author Information

  1. 1

    School of Clincial Sciences & Community Health, College of Medicine & Veterinary Medicine, Cochrane PVD Group, Public Health Sciences Section, Edinburgh, UK

  2. 2

    London School of Hygiene and Tropical Medicine, London, UK

*Freya Fowkes, Cochrane PVD Group, Public Health Sciences Section, School of Clincial Sciences & Community Health, College of Medicine & Veterinary Medicine, University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK. dr.fowkes@gmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 23 APR 2008

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Surgical bypass of an occluded arterial segment is one of the mainstay treatments for patients with critical limb ischaemia (CLI). However, it was introduced without formal evaluation.

Objectives

To determine the effects of bypass surgery in patients with CLI.

Search methods

The Cochrane Peripheral Vascular Diseases (PVD) Group searched their trials register (last searched 26 November 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (last searched Issue 4, 2007). We contacted principal trial investigators.

Selection criteria

All randomised controlled trials (RCTs) of bypass surgery versus control or any other treatment.

Data collection and analysis

For the update one author and PVD editorial staff extracted data and assessed trial quality. Unpublished data were obtained from trial investigators. Data were analyzed using Peto odds ratio (OR) or weighted mean difference (fixed and random effects models).

Main results

Nineteen trials were identified. Eight involved a total of just over 1200 patients. Four trials compared bypass surgery with angioplasty (PTA) and one each with thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. Four included patients with intermittent claudication (IC) and CLI, two were restricted to claudicants, and two to CLI. Vein grafts were used for distal reconstructions and synthetic prostheses for aorto-iliac or ilio-femoral bypasses. Six trials included mortality. In general, trial quality was good; blinding was not possible.

Mortality and amputation rates did not differ significantly between bypass surgery and PTA; primary patency was significantly higher in the bypass group after 12 months (Peto OR 1.6, 95% CI 1.0 to 2.6) but not after four years (P = 0.14). In patients with lower CLI, surgery was associated with increased surgical complications (Peto OR 2.69, 95% CI 1.87 to 3.86) and longer hospital stays during the first year, mean stay 46.1 days (SD 53.9) compared with 36.4 days (SD 51.4) for those receiving PTA (P < 0.0001). Amputation rates were significantly lower in bypass compared with thrombolysis (Peto OR 0.2, 95% CI 0.1 to 0.6); mortality rates did not differ. Blood flow restoration was significantly greater in bypass than in thromboendarterectomy patients (Peto OR 9.2, 95% CI 1.7 to 50.6); mortality and amputation rates did not differ. Bypass surgery outcomes did not differ significantly from exercise or spinal cord stimulation.

Authors' conclusions

There is limited evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to no treatment. Further large trials are required.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Bypass surgery for chronic lower limb ischaemia

There is not enough evidence to favour bypass surgery over angioplasty to treat chronic limb ischaemia (inadequate blood flow to the legs).

The most common symptom of arterial disease of the leg is claudication, a cramping pain caused by an inadequate supply of blood to the affected muscle. It often affects the calf muscle and is typically triggered by exercise and relieved by rest. More severe restriction of the blood supply may produce pain at rest, leg ulcers or gangrene. These conditions, and severe claudication, may require bypass surgery or angioplasty (repair by minor surgery) to improve blood flow to the leg. The review of trials found no evidence to favour bypass surgery over angioplasty in terms of the effect on walking distance, complications and disease progression, amputation rate or death. There was evidence in patients with critical lower limb ischaemia that surgery was associated with increased surgical complications and longer hospital stays than for those that received angioplasty. There was also no clear evidence to favour bypass surgery compared with other treatments. Further research is needed.