An Endovascular- Versus a Surgery-First Revascularization Strategy for Chronic Limb-Threatening Ischemia: A...

Area of Science:

• Vascular Surgery
• Interventional Cardiology
• Meta-Analysis

Background:

• Chronic limb-threatening ischemia (CLTI) necessitates timely revascularization for limb salvage and mortality reduction.
• The optimal revascularization strategy (endovascular-first vs. surgery-first) for CLTI patients eligible for both remains uncertain.
• Conflicting results from recent randomized controlled trials (RCTs) highlight the need for further comparative analysis.

Purpose of the Study:

• To conduct a trial-level meta-analysis comparing clinical outcomes of endovascular-first versus surgery-first revascularization strategies in patients with CLTI.
• To synthesize evidence from RCTs to inform clinical decision-making regarding revascularization approaches for CLTI.

Main Methods:

• A systematic literature search was performed across PubMed, Web of Science, and the Cochrane Library to identify relevant RCTs.
• Data from 3 RCTs, including 2,627 CLTI patients, were pooled using a random-effects model to calculate aggregate risk ratios (RRs) and hazard ratios (HRs).
• Outcomes analyzed included overall survival, amputation-free survival, reintervention rates, major amputation, and therapeutic crossover up to 5 years.

Main Results:

• No significant differences were observed between endovascular-first and surgery-first strategies regarding overall survival (HR 0.92 [0.83 to 1.01]) or amputation-free survival (HR 0.98 [0.92 to 1.03]).
• Rates of reintervention (RR 1.24 [0.74 to 2.07]), major amputation (RR 1.16 [0.87 to 1.54]), and therapeutic crossover (RR 0.92 [0.37 to 2.26]) also showed no statistically significant differences.
• The study included a substantial number of patients (2,627) with a majority being male (70.9%) and a notable proportion over 80 years old (13.2%).

Conclusions:

• Current evidence from RCTs suggests that neither an endovascular-first nor a surgery-first approach offers a significant advantage in clinical outcomes for CLTI patients.
• The findings indicate comparable efficacy between the two revascularization strategies in terms of limb salvage and survival.
• A future patient-level meta-analysis is recommended to provide more granular insights into treatment effectiveness for CLTI.