An endovascular- vs. a surgery-first revascularization strategy for chronic limb-threatening ischemia: A meta-analysis of randomized controlled trials.

BACKGROUND

Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results.

OBJECTIVE

We conducted a trial-level meta-analysis to compare outcomes between endovascular-first and surgery-first strategies for revascularization.

METHODS

PubMed, Web of Science and the Cochrane Library were searched to identify RCTs comparing outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using pooled aggregated data from published curves, with their corresponding Hazard Ratios (HR) and 95% CI reported for up to 5 years of follow-up.

RESULTS

Three RCTs with 2,627 patients (1,312 endovascular-first; 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 (70.9%) patients were male and 347 (13.2%) were older than 80 years of age. When comparing endovascular-first and surgery-first approaches, there was no significant difference in overall (HR: 0.92 [0.83-1.01], p=0.09) or amputation-free survival (HR: 0.98 [0.92-1.03], p=0.42), reintervention (RR: 1.24 [0.74-2.07], p=0.41), major amputation, (RR: 1.16 [0.87-1.54], p=0.31), or therapeutic crossover (RR: 0.92 [0.37-2.26], p=0.85).

CONCLUSION

Data from available RCTs suggest there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight.

Informations de copyright

Copyright © 2024. Published by Elsevier Inc.

Déclaration de conflit d'intérêts

Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Herebert Aronow reports a relationship with Philips that includes: consulting or advisory. Herbert Aronow reports a relationship with Medtronic that includes: consulting or advisory. Philip P. Goodney is a committee member contributing to the forthcoming patient-level meta-analysis of BEST-CLI and BASIL-2. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.