Surgery or Endovascular Therapy for Chronic Limb-Threatening Ischemia
Alik Farber1, Matthew T Menard1, Michael S Conte1
1From the Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine (A.F., M.F.V., J.A. Kalish, J.J.S.), the Division of Vascular and Endovascular Surgery (M.T.M., M.B.S.) and the Department of Medicine (N.K.C.), Brigham and Women's Hospital, Harvard Medical School (M.R.J.), and the Section of Vascular Medicine and Intervention, Massachusetts General Hospital (K.R.), Boston, HealthCore, Watertown (T.H.H., S.F.A., M.J.C., M.O., M.M.), and the Division of Vascular Surgery, UMass Memorial Health, Worcester (A.S.) - all in Massachusetts; the Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco (M.S.C., W.G., P.A.S.), the Division of Vascular Surgery, UC San Diego Health, La Jolla (A.B.), Coastal Cardiology, French Hospital Medical Center, San Luis Obispo (L.C.C.), and the Division of Vascular Surgery and Endovascular Therapy, University of Southern California, Los Angeles (V.L.R.) - all in California; the Department of Interventional Radiology (J.A. Kaufman) and the Division of Vascular Surgery, School of Medicine (A.A.), Oregon Health and Science University, and the Operative Care Division, Portland VA Medical Center (M.C.K.) - all in Portland; the Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH (R.J.P., M.A.C., P.P.G.); the Department of Medical Imaging, University of Arizona Health Sciences, Tucson (M.D.D.), and the Division of Vascular Surgery, Peak Heart and Vascular, Glendale (N.G.) - both in Arizona; the National Heart, Lung, and Blood Institute, Bethesda, MD (D.R., G.S.); the Medical Device Innovation Consortium, National Evaluation System for Health Technology Coordinating Center, Arlington, VA (F.S.S.); the Department of Cardiovascular Diseases, Ochsner Clinical School, University of Queensland, Brisbane, Australia (C.J.W.); the Department of Interventional Radiology, Gundersen Health System, La Crosse, WI (E.A.); the Iowa Heart Center, Des Moines (D.K.C.); the Division of Vascular Surgery, Centre Hospitalier Universitaire de Quebec-Université Laval, Quebec City (Y.D.), and Dalhousie University, Division of Cardiac and Vascular Surgery, Department of Surgery, Nova Scotia Health Association, Halifax (C.R.H.) - both in Canada; the Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta (L.F.); the Division of Vascular and Endovascular Surgery, Maine Medical Center, Portland (K.A.G.); the Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City (B.M.H.); Westchester Medical Center and the Department of Surgery, Section of Vascular Surgery, New York Medical College - both in Valhalla, NY (I.A.L.); the Vascular Medicine Outcomes Program, Yale University, New Haven, CT (C.M.-H.); the Division of Vascular Surgery, Indiana University School of Medicine, Indianapolis (R.M.); and the Department of Vascular Surgery, University of Helsinki, and Helsinki University Hospital - both in Helsinki (M.V.).
Surgical revascularization is superior to endovascular therapy for patients with chronic limb-threatening ischemia (CLTI) who have a usable great saphenous vein. For CLTI patients without a suitable vein, both strategies showed similar limb outcomes.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- Chronic limb-threatening ischemia (CLTI) poses a significant risk of amputation.
- Revascularization is crucial for improving limb perfusion in CLTI patients.
- The optimal initial revascularization strategy (endovascular vs. surgical) for CLTI remains uncertain.
Purpose of the Study:
- To compare the effectiveness of endovascular therapy versus surgical revascularization for CLTI.
- To evaluate limb and survival outcomes in patients undergoing different revascularization strategies.
Main Methods:
- An international, randomized trial involving 1830 patients with CLTI and infrainguinal peripheral artery disease.
- Two parallel cohorts: Cohort 1 (usable great saphenous vein) and Cohort 2 (alternative bypass conduit).
- Primary outcome: composite of major adverse limb event (amputation above ankle, major reintervention) or all-cause death.
Main Results:
- In Cohort 1, surgical revascularization significantly reduced the primary outcome compared to endovascular therapy (42.6% vs. 57.4%, HR 0.68).
- In Cohort 2, no significant difference in the primary outcome was observed between surgical and endovascular groups (42.8% vs. 47.7%, HR 0.79).
- Adverse event rates were similar between surgical and endovascular groups in both cohorts.
Conclusions:
- Surgical revascularization is superior for CLTI patients with an adequate great saphenous vein.
- For CLTI patients lacking a suitable saphenous vein conduit, endovascular therapy and surgical revascularization yield similar outcomes.
- The choice of revascularization strategy should consider the availability of a great saphenous vein.
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