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A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb

Emile B Veenstra¹, Maarten J van der Laan², Clark J Zeebregts²

¹Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands; Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands.

Journal of Vascular Surgery

|July 30, 2019

Insights

Catheter-driven thrombolysis (CDT) and surgical revascularization offer similar limb salvage rates for acute limb ischemia (ALI). However, CDT is linked to increased hemorrhagic complications, while specific thrombolytic agents show varied effectiveness.

Area of Science:

Vascular Surgery
Interventional Cardiology
Thrombosis Management

Background:

Acute limb ischemia (ALI) treatment strategies lack clear definition.
Comparison of catheter-driven thrombolysis (CDT) with surgical revascularization is needed.
Evaluation of various fibrinolytic agents and endovascular approaches for thrombectomy is essential.

Purpose of the Study:

To compare the safety and effectiveness of CDT versus surgical revascularization for ALI.
To evaluate different fibrinolytic agents and endovascular techniques for thrombectomy.

Main Methods:

Systematic literature search of PubMed, Embase, and Cochrane Library for ALI management studies.
Inclusion of randomized controlled trials, prospective, and retrospective studies comparing treatments.
Meta-analysis of 25 studies involving 4689 patients across nine comparisons.

Main Results:

Comparable limb salvage rates between thrombectomy and thrombolysis.
Higher incidence of major vascular events in the thrombolysis group (6.5%) versus surgical group (4.4%).
Recombinant tissue plasminogen activator (r-tPA) showed comparable limb salvage at different doses and superior 30-day salvage compared to streptokinase.

Conclusions:

CDT and surgery demonstrate similar limb salvage for ALI, but CDT carries a higher risk of hemorrhagic complications.
Insufficient data exist to establish definitive risks for hemorrhagic complications with specific thrombolytic agents (r-tPA, streptokinase, urokinase).
Further well-designed trials with standardized reporting are required to clarify optimal ALI treatment strategies.

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Abstract

Background:

The initial treatment of patients with acute limb ischemia (ALI) remains undefined. The aim of this article was to compare the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluate the various fibrinolytic agents, endovascular, and pharmacochemical approaches that aim for thrombectomy.

Methods:

PubMed, Embase, and the Cochrane Library were searched for studies on the management of ALI by means of surgical or endovascular recanalization, returning 520 studies. All randomized, controlled trials, nonrandomized prospective, and retrospective studies were included comparing treatment of ALI.

Results:

Twenty-five studies, investigating a total of 4689 patients, were included for meta-analysis spread across nine different comparisons. No differences were found in limb salvage between thrombectomy and thrombolysis. More major vascular events were seen in the thrombolysis group (6.5% compared with 4.4% in the surgically treated group; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87; P = .02; I² = 20%). Comparable limb salvage was found for high- and low-dose recombinant tissue plasminogen activator (r-tPA). No significant differences were found in major vascular event between low r-tPA (14%) and high r-tPA (10.5%; P = .13). The 30-day limb salvage rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; 95% CI, 1.26-7.85; P = .01; I² = 0%). AngioJet showed more limb salvage at 6 months compared with r-tPa (OR, 2.21; 95% CI, 1.17-4.18; P = .01; I² = 0%).

Conclusions:

Both CDT and surgery have comparable limb salvage rates in patients with ALI; however, CDT is associated with a higher risk of hemorrhagic complications. No conclusions can be drawn regarding the risk of hemorrhagic complications regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase. Insufficient data are available to conclude the preference of using a hybrid approach, ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical) thrombectomy systems. Future trials regarding ALI need to be constructed carefully, ensuring comparable study groups, and should follow standardized practices of outcome reporting.

Keywords:

Arterial occlusive diseases therapy Lower extremity blood supply Mechanical thrombolysis Thrombectomy Thrombolysis

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