Endovascular Management of Acute Lower Limb Ischaemia in Adult Patients: A Systematic Review and Meta-analysis

To perform a systematic review and meta-analysis of randomised trials and observational studies assessing outcomes of different endovascular management approaches for the treatment of acute lower limb ischaemia (ALI) when adjusted for Rutherford classification.

PubMed, Embase, Cochrane Library, and Web of Science.

A literature search was performed in PubMed, Embase, Cochrane Library, and Web of Science on 30 January 2025. Studies recruiting patients after the year 2000, assessing at least 10 adult patients with ALI, reporting Rutherford classification, and comparing different endovascular management approaches were included. The main outcomes of interest were 30 day death, 30 day major amputation, major bleeding, distal embolisation, acute kidney injury, and fasciotomy. Comparative studies reporting patients undergoing a combination of therapies without a clear order were excluded. If at least three studies reported unadjusted effect sizes, providing Rutherford classification for the groups under comparison, a multiple meta-regression random effects model was used to adjust for disease severity. Evidence certainty was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

A total of 9 801 publications were identified, of which 153 were selected for full text review, and seven were included in the systematic review and analysis. The available data only allowed one meta-regression analysis of three observational studies comparing AngioJet pharmacomechanical thrombolysis first vs. continuous catheter directed thrombolysis (recombinant tissue plasminogen activator) first, which showed no difference in 30 day mortality rates between groups in the unadjusted analysis (odds ratio 1.19, 95% confidence interval 0.38 - 3.67; p = .44; I² = 13%). Heterogeneity was low (p = .31; I² = 0%), and Rutherford classification IIb was not statistically significant (p = .58) in the meta-regression model. The level of certainty for the summarised evidence was very low.

The putative benefit of percutaneous endovascular thrombectomy over continuous catheter directed thrombolysis was not proven. The quality of summarised evidence was very low. Adequately powered high quality randomised trials are needed to assess the comparative efficacy of endovascular therapies in ALI.