Endovascular Therapy vs. Bypass Surgery for Critical Limb Ischemia

Study Questions:

Do endovascular techniques and bypass surgery as first-line treatment strategies for critical limb ischemia (CLI) result in similar amputation-free survival (AFS)?


Data from CRITISCH (Registry of First-Line Treatments in Patients With Critical Limb Ischemia), a prospective, multicenter registry, were used to evaluate first-line treatment of new-onset CLI. Twenty-seven centers with multispecialty CLI programs participated. All available endovascular techniques were included. This interim analysis was pre-planned with AFS as the primary outcome.


Endovascular treatment and bypass were performed on 643 and 284 participants, respectively. Participants undergoing endovascular treatment were older, higher risk, and had a greater prevalence of chronic kidney disease; those treated with bypass had a higher prevalence of previous intervention and TASC (Trans-Atlantic Inter-Society Consensus) C or D disease. Median follow-up was approximately 1 year, and no difference in AFS was observed between groups. Multivariable predictors of AFS were PREVENT III risk score and chronic kidney disease.


The authors concluded that AFS after first-line endovascular treatment for CLI was not inferior to bypass surgery.


Individualized treatment selection for CLI requires consideration of procedure-related risk, lesion characteristics, chance of technical success, and durability. Multidisciplinary CLI treatment by experienced clinicians yields similar AFS with endovascular and surgical approaches. Inferior outcomes among patients with CLI and chronic kidney disease suggest the need for specific management approaches that remain to be defined.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Aortic Surgery, Cardiac Surgery and Arrhythmias

Keywords: Amputation, Cardiac Surgical Procedures, Coronary Artery Bypass, Endovascular Procedures, Ischemia, Renal Insufficiency, Chronic, Risk, Secondary Prevention, Survival, Vascular Diseases

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