A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

Abstract

Background: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. Methods: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. Results: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. Conclusions: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

Limb‐salvage surgery with vascular reconstruction after lower extremity sarcoma resection: A systematic review and meta‐analysis

“…Most current reconstructive procedures consist of interposition of the vessel defect with autologous or synthetic grafts because en bloc resection usually necessitates resection of a long segment of vessels. Previous review articles about obstructive arterial disease demonstrated that graft selection could influence the long‐term limb‐salvage rate, and autologous graft is superior to synthetic graft in patency (Almasri et al, ; Klinkert, Post, Breslau, & van Bockel, ). However, in sarcoma surgery in contrast to obstructive arterial disease, there are some specific situations, such as requirement of a relatively short graft, not atherosclerotic artery, and postoperative formation of arterial collateral.…”

Radial Access for Lower Extremity Peripheral Arterial Interventions: Do We Have the Tools?

“…Devices with approximately 150 to 180 cm working lengths are required to treat infrapopliteal PAD. 38 A recent meta-analysis by Almasri et al 39 examining revascularization outcomes of infrainguinal CLI (44 studies, 8,602 total patients) showed that drug-eluting stents have improved patency over bare metal stents in infrapopliteal arteries (73 vs. 50%) and comparable to balloon angioplasty (66% primary patency) at 1 year. There are no stents or drug-coated balloons that reach this distance.…”

The Association of Preoperative Characteristics with Reintervention Risk in Patients Undergoing Revascularization for Chronic Limb-Threatening Ischemia

“…timal durability of the associated devices, EVT has yet to provide clinical results that are equivalent to those of surgical reconstruction [6][7][8] The importance of surgical therapy has been consistently highlighted in the latest guidelines particularly because patients frequently require reintervention after EVT 5) . In fact, the Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia (SPIN-ACH) study recently found that CLTI patients undergoing EVT had a higher risk of reintervention than a matched population undergoing surgical reconstruction, although no significant differences were observed with regard to major amputation or all-cause mortality 7) .…”