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Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia
K Benjamin Lee1, Robyn A Macsata1, Salim Lala1
1Department of Surgery, George Washington University, Washington, DC, USA.
Insights
Open surgical intervention offers better limb salvage for chronic limb-threatening ischemia with tissue loss compared to endovascular therapy. This approach should be prioritized for eligible patients, enhancing amputation-free survival.
Area of Science:
- Vascular Surgery
- Cardiovascular Interventions
- Limb Salvage Procedures
Background:
- Endovascular therapy is increasingly adopted for chronic limb-threatening ischemia (CLTI).
- Defining optimal treatment strategies for limb salvage remains crucial in vascular surgery.
- Open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) are primary revascularization methods for CLTI.
Purpose of the Study:
- To compare the effectiveness of OPEN versus ENDO for limb salvage in patients with CLTI.
- To identify specific patient subgroups where OPEN provides superior outcomes.
- To evaluate the impact of intervention type on mortality, amputation, and adverse cardiovascular events.
Main Methods:
- Retrospective analysis of the National Surgical Quality Improvement Program database (2011-2017).
- Inclusion of patients with CLTI undergoing OPEN or ENDO.
- Stratification based on clinical presentation (rest pain or tissue loss) and arterial location (femoropopliteal or tibioperoneal).
Main Results:
- OPEN was associated with higher 30-day mortality and complications but significantly lower major amputation rates (3.8% vs. 5.0%).
- OPEN demonstrated superior limb salvage for patients with tissue loss in both femoropopliteal and tibioperoneal disease.
- No significant amputation reduction benefit from OPEN was observed in patients with rest pain.
Conclusions:
- Open surgical intervention is associated with significantly better limb salvage in patients with CLTI and tissue loss.
- OPEN should be considered a primary treatment option for CLTI with tissue loss, barring prohibitive cardiopulmonary risk.
- Further emphasis on surgical options may improve outcomes for select CLTI patients.
Objectives:
Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage.
Methods:
Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events.
Results:
A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain.
Conclusions:
Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
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