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, 2018;Klinkert, Post, Breslau, & van Bockel, 2004). 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.…”

Feasibility of ischemic leg ulcer healing using percutaneous techniques: a real-life study

“…In our study, adverse events occurred in 9% of patients, mainly access-related and peri-procedural mortality was 0%, compared to a roughly 3% mortality rate and 20% major complication rate of infra-inguinal bypass (28–30). Furthermore, in clinical research, the mortality rate of patients with intermittent claudication is 2.5 times higher than age-matched controls, while patients with CLI present a mortality rate as high as 20% the first year after diagnosis (4,10).…”

Limb-Based Patency After Surgical vs Endovascular Revascularization in Patients with Chronic Limb-Threatening Ischemia

“…Recent meta-analyses demonstrated high primary, assisted primary, and secondary patency rates after bypass surgery. 8,9 However, despite the difference in anatomic patency rates, the survival, limb salvage, and amputation-free survival rates have been comparable between the 2 treatment methods. 8-11…”