Use of Completion Imaging After Lower Extremity Bypass Decreasing

One-year rates of MALE and loss of primary patency have increased as use of completion imaging following lower extremity bypass has been decreasing.

Completion imaging use for proximal and distal target bypasses has decreased between 2003 and 2020, and 1-year major adverse limb event (MALE) rates and loss of primary patency (LPP) have increased, according to a study in the Annals of Vascular Surgery.

Researchers evaluated national trends in completion imaging use following lower extremity bypasses (LEBs) and the relationship between routine completion imaging and 1-year MALE and loss of primary patency with use of the Vascular Quality Initiative (VQI). Participants received LEB between 2003 and 2020.

The cohort was classified according to the surgeons’ completion imaging strategy at time of LEB: routine (≥80% of cases/year), selective (<80% of cases/year), or never. Participants were further stratified by surgeon volume category into 3 groups based on the number of cases performed by each surgeon per year: low (<25th percentile per year), medium (25th-75th percentile per year), or high (>75th percentile per year).

The primary outcomes were 1-year MALE-free survival and 1-year loss of primary patency-free survival.

The analysis included 37,919 patients, of whom 22.7% were treated by surgeons who never performed completion imaging, 58.4% by surgeons who performed completion imaging selectively, and 18.8% by surgeons who routinely performed completion imaging. The patients in all 3 groups had a mean age of 68.11 years, and 68% were men.

At 1 year, CI use was not associated with improved MALE-free or LPP-free survival.

A statistically significant steady decrease in completion imaging use occurred from 77.2% in 2003 to 32.0% in 2020 (P <.001). Among patients with grafts that had more distal infrageniculate targets (tibioperoneal trunk, anterior tibial, posterior tibial, peroneal) a similar trend was observed (86.0% in 2003 vs 36.9% in 2020; P <.001). During the same time period, 1-year MALE rates increased from 44.4% in 2003 to 50.4% in 2020 (P <.001).

In multivariate Cox regression, the surgeons’ use of completion imaging or their completion imaging strategy did not affect the risk for 1-year MALE or loss of primary patency. Grafts with tibial outflows were associated with an increased risk for 1-year MALE (hazard ratio [HR], 2.09; 95% CI, 1.46-3.01; P <.001) and loss of primary patency (HR, 2.05; 95% CI, 1.26-3.32; P <.001). Procedures by high-volume surgeons were associated with a lower risk for 1-year MALE (HR, 0.84; 95% CI, 0.75-0.95; P =.006) and loss of primary patency (HR, 0.83; 95% CI, 0.71-0.97; P <.001) vs low-volume surgeons.

In analyses stratified by surgeon volume category to assess the effects of completion imaging, no association was found between completion imaging use or surgeons’ completion imaging strategy and the primary outcomes in any of the subgroups.

Limitations of the study include the use of retrospective analysis, and completion imaging findings were not reported in the VQI. Also, the findings may not reflect practice patterns among all surgeons, and errors in data collection and missing information likely occurred. Furthermore, selection bias is possible and no causality can be determined.

“Our data indicate that CI [completion imaging] use has decreased over time while 1-year MALE rates and LPP [loss of primary patency] have increased,” wrote the study authors. “A significant drop in the use of intraoperative angiography is noted. At 1 year, CI use was not associated with improved MALE-free or LPP-free survival. All CI strategies, whether routine, selective, or never performing CI, were found to have no effect on outcomes independent of surgeon volume.”


Habib SG, Abdul-Malak OM, Madigan M, Salem K, Eslami MH. Trends in utilization of completion imaging after lower extremity bypass and its association with major adverse limb events and loss of primary patency. Ann Vasc Surg. Published online May 10, 2023. doi: 10.1016/j.avsg.2023.04.028