Bypass versus angioplasty to treat severe limb ischemia: Factors that affect treatment preferences of UK surgeons and interventional radiologists

Objective: There is continuing controversy as to whether surgical bypass or angioplasty should be first-line treatment of severe limb ischemia. We undertook this study to examine angiographic and clinical factors that influence the treatment of severe limb ischemia by vascular surgeons and interventional radiologists. Methods: Twenty consultant vascular surgeons and 17 consultant vascular interventional radiologists evaluated 596 hypothetical clinical or angiographic scenarios, and recorded whether, in their opinion, the most appropriate first-line treatment was surgical bypass, angioplasty, or primary amputation. Stepwise multiple linear regression was used to identify the factors that significantly affected responses from the entire group and from surgeons and radiologists separately. Results: There were significant differences between surgeons and radiologists with regard to how clinical and angiographic variables determined treatment preferences. Increasing disease severity, absence of runoff into the foot, presence of a suitable vein, and tissue loss as opposed to rest pain only (the latter only significant to surgeons) all increased the response score toward surgery. However, surgeons and radiologists weighted each of these factors quite differently. Even in the most complex statistical model, 19% of surgical and 13% of radiologic response variations remained unexplained. Conclusions: Individual surgeons and radiologists vary considerably in their views of the relative merits of surgery and angioplasty in patients with severe limb ischemia. This broad gray area mandates the need for randomized controlled trial data to inform joint decision-making and to optimize patient outcome.