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When should open surgery be the initial option for critical limb ischaemia?

P F Lawrence¹, A Chandra

¹Division of Vascular Surgery, Gonda (Goldschmied) Vascular Center, David Geffen School of Medicine at UCLA, 200 Medical Plaza, Ste. #510-6, Los Angeles, CA 90095-6908, USA. pflawrence@mednet.ucla.edu

European Journal of Vascular and Endovascular Surgery : the Official Journal of the European Society for Vascular Surgery

|January 15, 2010

Summary

Treatment for critical limb ischaemia (CLI) now includes more endovascular interventions. While endovascular therapy is increasing, open surgery remains optimal for specific CLI cases, guiding future patient-specific treatment decisions.

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Area of Science:

Vascular Surgery
Interventional Cardiology
Vascular Medicine

Background:

The treatment landscape for critical limb ischaemia (CLI) has evolved, with a notable rise in endovascular interventions over the past decade.
This shift prompts a critical evaluation of whether open surgical procedures or endovascular therapies offer the optimal approach for CLI management.

Purpose of the Study:

To review and compare the evidence supporting 'open first' versus 'endo first' strategies for treating critical limb ischaemia.
To identify specific clinical scenarios where open surgery is preferred for CLI based on expert consensus and current literature.

Main Methods:

A comprehensive literature review was conducted comparing open surgical and endovascular interventions for CLI.
Arguments for both 'open first' and 'endo first' approaches were summarized.
An informal survey of endovascular surgeons identified key indications for prioritizing open surgery in CLI.

Main Results:

Current level 1 evidence does not fully support claims for either an exclusive 'open first' or 'endo first' approach.
Endovascular surgeons identified five key indications for open surgical revascularization in CLI: common femoral artery pathology, extrinsic compression, extensive foot gangrene/sepsis, young patients needing durable reconstructions, and specific infrageniculate/tibial occlusions.
Clinical scoring systems and mathematical modeling can aid in objective intervention decisions for lower extremity disease.

Conclusions:

The optimal treatment for CLI is evolving, with ongoing research focusing on intervention effectiveness.
Despite the increase in endovascular procedures, specific indications for open surgical treatment of CLI persist.
Further research aims to establish clearer, patient-specific guidelines for choosing between open and endovascular interventions in CLI.