Contemporary Outcomes of Endovascular vs Surgical Revascularization for Acute Limb Ischemia (ALI)

Abstract

The purpose of this study was to compare contemporary endovascular with surgical revascularization for ALI. Consecutive patients with ALI treated with endovascular (ER) or surgical revascularization (OR) between 2005 and 2011 were identified and reviewed. Procedural success and outcomes were compared between the two groups. Limb salvage and survival were assessed using time-to-event methods, including Kaplan-Meier estimation and competing-risks regression models. One-hundred fifty-four limbs were treated in 147 patients in the ER group, compared with 330 limbs in 296 patients in the OR group. Patient characteristics, severity of ischemia, and indications for intervention are presented in the Table. The mean follow-up was 14 months. Overall technical success was achieved in 80.5% (ER) vs 88.6% (OR) (P = .019). Thirty-day mortality rate was 5.4% (ER) and 13.2% (OR) (P = .013). Amputation rates were 6.5% (ER) vs13.3% (OR) at 30 days (P = .027), and 13.0% (ER) and 19.7% (OR) at 1 year (P = .075). The primary patency was 57% (ER) and 53% (OR) at 1 year (P = .301). Rutherford class 2 ischemia represented the majority of our patients, where overall technical success was 79.9% (ER) vs 91.5% (OR) (P = .001). Technical success in this class was higher with OR when performed for a failed bypass (94.7% OR vs 75% ER; P = .001), but with similar 1-year amputation rates (25.0% OR vs 23.1% ER; P = .84). Technical success was comparable between the two groups for patients treated for embolic ALI or in situ thrombosis, as were the amputation rates at 30 days and 1 year (P = NS). Predictors of limb loss by life table analysis included coronary artery disease (SHR = 2.24; P = .005) and end stage renal disease/dialysis (SHR = 2.76; P = .031). Predictors of death by life table analysis included age (SHR = 1.02; P = .001), end-stage renal disease (SHR = 5.67; P < .001), cancer (SHR = 1.48; P = .02), and rhabdomyolysis (SHR = 3.07; P < .01). Patients presenting with Rutherford class 2 ALI are commonly treated with endovascular or surgical revascularization with comparable outcomes and limb salvage rates for most indications. Although technical success is higher with open revascularization for patients presenting with failed bypass grafts, the amputation rates are comparable. Mortality rates are significantly higher at 30 days and 1 year in the OR group.TablePatient characteristics, severity of ischemia, and indications for interventionOpen surgical group, No. (%)Endovascular group, No. (%)P valueSmoking<.001 No151 (51.4)37 (25.5) Former49 (16.7)42 (29.0) Current94 (32.066 (45.5)Comorbidities Coronary artery disease144 (48.8)79 (55.2).21 End-stage renal disease/dialysis12 (4.1)6 (4.2).95 Congestive heart failure57 (19.3)28 (19.6).95 Chronic obstructive pulmonary86 (29.2)33 (23.1).18 disease Atrial fibrillation114 (38.6)32 (22.4).001 Chronic renal insufficiency39 (13.2)31 (22.0).02 Diabetes91 (30.9)57 (40.1).06Cause of ischemia Cardiac embolism85 (27.1)14 (9.1)<.001 Native artery thrombosis103 (32.8)37 (24).05 Failed stent32 (10.1)41 (26.6)<.001 Failed bypass98 (31.0)56 (36.4).25 Thrombosed peripheral aneurysm18 (5.7)6 (3.9).41 Aortoiliac embolism13 (4.1)8 (5.2).61Distribution by severity Rutherford I4 (1.27)15 (9.74) Rutherford IIa127 (40.19)108 (70.13) Rutherford IIb132 (41.77)31 (20.13) Rutherford III13 (4.11)0 (0) Open table in a new tab