Conservative Treatment of Patients with Chronic Limb Threatening Ischemia: Systematic Review and Meta-Analysis

Abstract

Introduction: Critical limb threatening ischemia (CLTI) is the most severe form of peripheral arterial disease, characterized by chronic ischemic rest pain, ulcers, or gangrene, and carries a high risk of amputation. International consensus advocates revascularization therapy. However, patients with CLTI are often fragile elderly with significant comorbidities, while their vascular anatomy is not always suitable for open or endovascular revascularization. Recent studies have suggested fair outcomes of conservative treatment in some cases. Therefore, we systematically reviewed the outcomes of conservative treatment in patients with CLTI. Methods: The review was conducted following PRISMA guidelines. PUBMED, EMBASE and COCHRANE CENTRAL databases were searched from inception until September 2018. Studies were eligible when reporting on outcomes of conservative treatment of CLTI. Study selection, data extraction and quality assessment were done by two investigators independently. Risk of bias was evaluated with the use of a modified version of the Cochrane risk of bias tool for observational studies. Outcomes of interest were amputation-free survival (AFS), major amputation and mortality after at least 12 months of follow-up. A random effects model was used for meta-analyses, if feasible. Results: A total of 27 publications were included, consisting of twenty prospective and seven retrospective studies comprising 1876 patients. Most studies included patients with no-option CLTI. Overall study quality was moderate. The pooled mortality rate after 12 months of follow-up of 15 studies consisting of 1295 patients was 18% (95% CI 12 - 26%, I2 = 89%). The major amputation rate from 15 studies comprising 1047 patients was 26% (95% CI 19 - 35%, I2 = 81%) and the AFS rate of 10 studies with 860 patients included was 51% (35 - 67% I2 = 94%). During the past 30 years, major amputation and AFS rates appear to have improved in conservatively treated CLTI patients. Conclusion: Conservative treatment can be a feasible treatment option in CLTI patients without revascularization opportunities, or when patients are fragile and present with significant comorbidities. Disclosure: Nothing to disclose