An endovascular- vs. a surgery-first revascularization strategy for chronic limb-threatening ischemia: A meta-analysis of randomized controlled trials
Author Department
Cardiology; Medicine
Document Type
Article, Peer-reviewed
Publication Date
1-2024
Abstract
Background: Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results.
Objective: We conducted a trial-level meta-analysis to compare outcomes between endovascular-first and surgery-first strategies for revascularization.
Methods: PubMed, Web of Science and the Cochrane Library were searched to identify RCTs comparing outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using pooled aggregated data from published curves, with their corresponding Hazard Ratios (HR) and 95% CI reported for up to 5 years of follow-up.
Results: Three RCTs with 2,627 patients (1,312 endovascular-first; 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 (70.9%) patients were male and 347 (13.2%) were older than 80 years of age. When comparing endovascular-first and surgery-first approaches, there was no significant difference in overall (HR: 0.92 [0.83-1.01], p=0.09) or amputation-free survival (HR: 0.98 [0.92-1.03], p=0.42), reintervention (RR: 1.24 [0.74-2.07], p=0.41), major amputation, (RR: 1.16 [0.87-1.54], p=0.31), or therapeutic crossover (RR: 0.92 [0.37-2.26], p=0.85).
Conclusion: Data from available RCTs suggest there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight.
Keywords: CLTI; Chronic limb threatening ischemia; Critical limb ischemia; Endovascular; Endovascular vs. surgical; Surgical.
Recommended Citation
Mufarrih SH, Khan MS, Qureshi NQ, Akbar MS, Kazimuddin M, Goldsweig AM, Goodney PP, Aronow HD. An endovascular- vs. a surgery-first revascularization strategy for chronic limb-threatening ischemia: A meta-analysis of randomized controlled trials. Am J Cardiol. 2024 Jan 15:S0002-9149(24)00039-0. doi: 10.1016/j.amjcard.2024.01.007. Epub ahead of print.
PMID
38232807