July 30, 2019
2 min read

Endovascular-first approach bests open surgery for amputation-free survival in CLI

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Patients with critical limb ischemia and multiple comorbidities who underwent initial surgical bypass had lower rates of amputation-free survival compared with those who underwent an endovascular-first approach, according to a study published in Circulation: Cardiovascular Quality and Outcomes.

“The data here suggest that in the grand scheme of things, an endovascular-first approach is at least not producing a worse result,” Jonathan H. Lin, MD, surgery resident at UC Davis Health, said in a press release. “Regardless, the type of therapy a patient will receive needs to be a decision that patients and their physicians arrive at together. Critical limb ischemia is usually not an emergency, and there is time to determine the most appropriate course of therapy.”

Researchers analyzed data from 16,800 patients (mean age, 71 years; 59% men) with lower-extremity ulcers and PAD who underwent a revascularization procedure between 2005 and 2013. The primary outcome was amputation-free survival, and the secondary outcomes were all-cause mortality and reintervention.

Of the patients in the study, 36% underwent open surgical bypass as the initial treatment and 64% underwent endovascular-first interventions. Compared with the open-first group, those in the endovascular-first group were more likely to be younger (70 years vs. 72 years; P < .001) and had higher rates of CAD (34% vs. 32%; P < .05), renal failure (36% vs. 24%; P < .05), diabetes (65% vs. 58%; P < .05) and congestive HF (19% vs. 15%; P < .05).

Researchers also performed inverse propensity weighting and an adjustment for hospital revascularization experience and a patient’s ability to manage their disease. After these adjustments, patients who were treated with open surgery first had worse amputation-free survival compared with those treated with an endovascular intervention first (HR = 1.16; 95% CI, 1.13-1.2). There was no difference in overall mortality in the open surgery-first group vs. the endovascular-first group (HR = 0.94; 95% CI, 0.89-1.11). Patients who underwent endovascular-first treatments had higher rates of reinterventions compared with those who underwent open surgery first (HR = 1.19; 95% CI, 1.14-1.23).

“It is difficult to conclude the reason behind this finding using the present data set; however, we hypothesize that this may be in part due to the increased severity of ischemic wounds at the time of presentation,” Lin and colleagues wrote. “The direction of future studies will focus on controlling for severity to further evaluate the outcome of these two therapeutic strategies.” – by Darlene Dobkowski

Disclosures: The authors report no relevant financial disclosures.