Endovascular-first revascularization is as safe and efficacious as open-first revascularization for acute limb...

The independent effect of the initial revascularization strategy-open surgery-first (OS) vs endovascular-first (EV)-on the outcomes in acute limb ischemia (ALI) remains uncertain because of limited contemporary comparative effectiveness data. We evaluated amputation-free survival (AFS) after OS vs EV revascularization and examined the clinical factors associated with the outcomes.

We performed a two-center retrospective cohort study of adults presenting with ALI. Patients were categorized according to the initial treatment strategy: OS (surgical thrombectomy with or without endarterectomy or bypass) or EV (catheter-directed thrombolysis, rheolytic thrombectomy, or vacuum-assisted aspiration thrombectomy with adjunctive angioplasty, stenting, or atherectomy). The outcomes included major amputation, mortality, and AFS at 90 days and the last follow-up. Univariable and multivariable Cox proportional hazards analyses were performed.

Over 9 years, a total of 367 patients (394 limbs; bilateral involvement in 27 patients [7.4%]) were included in this study (median age = 65.5 years [interquartile range {IQR} = 56-75]; 55.3% male; median follow-up of 614 days [IQR = 172-1223]). Patients treated with EV revascularization (n = 186) more frequently had long-term atherosclerotic risk factors, whereas embolic etiologies were more common in the OS group (n = 181). Length of hospital stay was shorter in the EV group than in the OS group (5 days [IQR = 2-11] vs 6 days [IQR = 3-13]; P = .006). At 90 days, the outcomes in the EV vs OS groups were as follows: major amputation, 12.4% vs 15.9% (P = .32); mortality, 10.7% vs 15.4% (P = .17); and AFS, 78.9% vs 71.4% (P = .08), respectively. Reinterventions were more frequent after the EV treatment (46.6% vs 26.4%; P < .001). At the last follow-up, the EV strategy was associated with improved survival (mean = 6.2 vs 4.7 years; log-rank P = .003) and AFS (4.9 vs 3.6 years; P = .01), whereas limb loss did not differ between the strategies. In multivariable analysis, Rutherford ischemia class (hazard ratio, 2.26; 95% confidence interval, 1.48-3.48; P < .001) and congestive heart failure (hazard ratio, 1.58; 95% confidence interval, 1.00-2.49; P = .04) were independently associated with major amputation or death. Subgroup analyses revealed no differences in AFS by sex (23% vs 28%; P = .28) or by embolic vs thrombotic presentation (25% vs 25%; P = .93). Vacuum-assisted aspiration thrombectomy was associated with fewer 90-day deaths/major amputations (20.4% vs 36.7%; P = .004), whereas rheolytic thrombectomy provided no measurable benefit.

In this contemporary, large, two-center cohort study, the OS and EV strategies demonstrated similar 90-day safety and efficacy for ALI. Although the EV strategy was associated with higher reintervention rates, it was associated with improved long-term survival and AFS. Baseline Rutherford class led to more than twofold increases in the hazard of major amputation or death. These findings support individualized treatment selection based on clinical presentation and the ischemic burden.