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Published on: September 22, 2020
Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive
Jiarong Wang1,2, Chi Shu1,2, Zhoupeng Wu2
1West China School of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
Insights
Percutaneous vascular interventions (PVI) show better short-term outcomes for critical limb ischemia (CLI) patients, reducing mortality and complications. However, bypass surgery (BSX) may be preferable for long-term survival, especially with autogenous grafts.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Critical Limb Ischemia Treatment
Background:
- Treatment strategies for critical limb ischemia (CLI) remain controversial.
- Previous reviews lacked strict inclusion criteria, potentially biasing results.
- The optimal revascularization strategy for CLI requires further investigation.
Purpose of the Study:
- To compare percutaneous vascular interventions (PVI) against bypass surgeries (BSX) in patients with critical limb ischemia (CLI).
- To evaluate the efficacy and safety of PVI versus BSX for CLI revascularization.
- To provide evidence-based recommendations for CLI treatment strategies.
Main Methods:
- Meta-analysis of randomized controlled trials and observational clinical studies.
- Inclusion criteria focused exclusively on patients with critical limb ischemia (CLI).
- Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events.
Main Results:
- PVI reduced 30-day mortality, major adverse events, and surgical site infections compared to BSX.
- PVI increased risks of long-term all-cause mortality and primary patency failure.
- PVI showed inferior outcomes compared to autogenous bypass surgery for infrapopliteal lesions.
Conclusions:
- Bypass surgery (BSX) may be a better long-term option for CLI patients in good physical condition with long life expectancy, especially with autogenous grafts.
- Enhanced perioperative care for BSX is crucial to match PVI's short-term outcomes.
- The choice between PVI and BSX should be individualized based on patient factors and lesion characteristics.
Objective:
The aim of our study was to compare percutaneous vascular interventions (PVI) versus bypass surgeries (BSX) in patients with critical limb ischemia (CLI).
Background:
Previous relevant reviews with limited numbers of included studies did not strictly confine the inclusion criteria to CLI, also involving patients with severe claudication, which may introduce bias in the decision-making of CLI revascularization. Current treatment strategies for CLI still remain controversial.
Methods:
We performed a meta-analysis of all available randomized controlled trials and observational clinical studies comparing PVI with BSX in CLI patients. Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events.
Results:
We identified 45 cohorts and 1 RCT in over 20,903 patients. In overall population, PVI reduced the risks of 30-day mortality [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.51-0.95), major adverse cardiovascular and cerebrovascular events (OR 0.42, 95% CI 0.29-0.61), and surgical site infection (OR 0.31, 95% CI 0.19-0.51), but increased the risks of long-term all-cause mortality [hazard ratio (HR) 1.16, 95% CI 1.05-1.27) and primary patency failure (HR 1.31, 95% CI 1.08-1.58). When compared with autogenous BSX, PVI was also associated with additional increased risks of long-term death or amputation (HR 1.41, 95% CI 1.02-1.94) and secondary patency failure (HR 1.51, 95% CI 1.17-1.95). In patients with infrapopliteal lesions, we found PVI had inferior primary patency (HR 1.39, 95% CI 1.10-1.75) compared with BSX.
Conclusion:
For patients in good physical condition with long life-expectancy, BSX may represent a better choice compared with PVI, particularly when autogenous bypass is available. While enhanced perioperative care for cardiovascular events and surgical site should be considered in patients underwent BSX to achieve comparable short-term outcomes provided by PVI.
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