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Endovascular-First vs. Open-First Critical Limb Ischemia Treatment
Study Questions:
What are the amputation-free survival and reintervention rates in patients treated with initial open surgical bypass or endovascular intervention for ischemic ulcers of the lower extremities?
Methods:
The investigators used the California nonfederal hospital data linked to statewide death data to identify all patients with lower extremity ulcers and a diagnosis of peripheral artery disease who underwent a revascularization procedure from 2005 to 2013. Propensity scores were formulated from baseline patient characteristics. Inverse probability weighting was used with Kaplan–Meier analysis to determine amputation-free survival and time to reintervention for open versus endovascular treatment. Mixed-effects Cox proportional hazards modeling was used to adjust for ability of patients to manage their disease and hospital revascularization volume.
Results:
A total of 16,800 patients were identified. Open surgical bypass was the initial treatment in 5,970 (36%), while 10,830 (64%) underwent endovascular interventions. Patients in the endovascular group were slightly younger compared with the open group (70 vs. 71 years, ±12 years; p < 0.001). Endovascular-first patients were more likely to have comorbid renal failure (36% vs. 24%), coronary artery disease (34% vs. 32%), congestive heart failure (19% vs. 15%), and diabetes mellitus (65% vs. 58%; all p values < 0.05). After inverse propensity weighting as well as adjustment for ability of patients to manage their disease and hospital revascularization experience, open surgery-first was associated with a worse amputation-free survival (hazard ratio [HR], 1.16; 95% confidence interval [CI], 1.13–1.20) with no difference in mortality (HR, 0.94; 95% CI, 0.89–1.11). Endovascular-first was associated with higher rates of reintervention (HR, 1.19; 95% CI, 1.14–1.23).
Conclusions:
The authors concluded that initial surgical bypass is associated with poorer amputation-free survival compared with an endovascular-first approach among patients with critical limb ischemia (CLI).
Perspective:
This state-based data analysis reports that an initial open surgical bypass approach for patients with CLI was associated with worse amputation-free survival but decreased secondary procedures with no difference in overall mortality compared with an endovascular-first approach. This may be in part due to the increased severity of ischemic wounds at the time of presentation and multiple comorbidities in those with CLI. These results suggest that endovascular-first is a reasonable strategy in patients with CLI pending prospective validation studies controlling for severity to further evaluate the outcome of the surgical- versus endovascular-first option.
Keywords: Cardiac Surgical Procedures, Comorbidity, Coronary Artery Disease, Diabetes Mellitus, Endovascular Procedures, Geriatrics, Heart Failure, Ischemia, Leg Ulcer, Lower Extremity, Myocardial Revascularization, Peripheral Arterial Disease, Primary Prevention, Renal Insufficiency, Ulcer, Vascular Diseases
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