A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

Jehad Almasri, Jayanth Adusumalli, Noor Asi, Sumaya Lakis, Mouaz Alsawas, Larry J. Prokop, Andrew Bradbury, Philippe Kolh, Michael S. Conte, Mohammad H Murad

Research output: Contribution to journalArticle

Abstract

Background: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI)remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. Methods: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. Results: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events)were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively)compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. Conclusions: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day)mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

Original languageEnglish (US)
Pages (from-to)126S-136S
JournalJournal of vascular surgery
Volume69
Issue number6
DOIs
StatePublished - Jun 1 2019

Fingerprint

Meta-Analysis
Ischemia
Extremities
Amputation
Drug-Eluting Stents
Saphenous Vein
Veins
Knee
Limb Salvage
Balloon Angioplasty
Survival
Mortality
Angioplasty
Stents
Anatomy
Arteries
Metals
Outcome Assessment (Health Care)
Databases
Prospective Studies

Keywords

  • Bypass surgery
  • Critical limb ischemia
  • Endovascular treatment
  • Revascularization
  • Severe limb ischemia

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. / Almasri, Jehad; Adusumalli, Jayanth; Asi, Noor; Lakis, Sumaya; Alsawas, Mouaz; Prokop, Larry J.; Bradbury, Andrew; Kolh, Philippe; Conte, Michael S.; Murad, Mohammad H.

In: Journal of vascular surgery, Vol. 69, No. 6, 01.06.2019, p. 126S-136S.

Research output: Contribution to journalArticle

Almasri, J, Adusumalli, J, Asi, N, Lakis, S, Alsawas, M, Prokop, LJ, Bradbury, A, Kolh, P, Conte, MS & Murad, MH 2019, 'A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia', Journal of vascular surgery, vol. 69, no. 6, pp. 126S-136S. https://doi.org/10.1016/j.jvs.2018.01.071
Almasri, Jehad ; Adusumalli, Jayanth ; Asi, Noor ; Lakis, Sumaya ; Alsawas, Mouaz ; Prokop, Larry J. ; Bradbury, Andrew ; Kolh, Philippe ; Conte, Michael S. ; Murad, Mohammad H. / A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. In: Journal of vascular surgery. 2019 ; Vol. 69, No. 6. pp. 126S-136S.
@article{37b3f282cb3a4288ab9e68e04b65b04f,
title = "A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia",
abstract = "Background: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI)remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. Methods: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. Results: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events)were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87{\%}, 78{\%}; secondary: 94{\%}, 87{\%}, respectively)compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73{\%} vs 50{\%} at 1 year), and was at least comparable to balloon angioplasty (66{\%} primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. Conclusions: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day)mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.",
keywords = "Bypass surgery, Critical limb ischemia, Endovascular treatment, Revascularization, Severe limb ischemia",
author = "Jehad Almasri and Jayanth Adusumalli and Noor Asi and Sumaya Lakis and Mouaz Alsawas and Prokop, {Larry J.} and Andrew Bradbury and Philippe Kolh and Conte, {Michael S.} and Murad, {Mohammad H}",
year = "2019",
month = "6",
day = "1",
doi = "10.1016/j.jvs.2018.01.071",
language = "English (US)",
volume = "69",
pages = "126S--136S",
journal = "Journal of Vascular Surgery",
issn = "0741-5214",
publisher = "Mosby Inc.",
number = "6",

}

TY - JOUR

T1 - A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

AU - Almasri, Jehad

AU - Adusumalli, Jayanth

AU - Asi, Noor

AU - Lakis, Sumaya

AU - Alsawas, Mouaz

AU - Prokop, Larry J.

AU - Bradbury, Andrew

AU - Kolh, Philippe

AU - Conte, Michael S.

AU - Murad, Mohammad H

PY - 2019/6/1

Y1 - 2019/6/1

N2 - Background: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI)remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. Methods: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. Results: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events)were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively)compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. Conclusions: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day)mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

AB - Background: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI)remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence. Methods: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies. Results: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events)were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively)compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low. Conclusions: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day)mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

KW - Bypass surgery

KW - Critical limb ischemia

KW - Endovascular treatment

KW - Revascularization

KW - Severe limb ischemia

UR - http://www.scopus.com/inward/record.url?scp=85065792175&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85065792175&partnerID=8YFLogxK

U2 - 10.1016/j.jvs.2018.01.071

DO - 10.1016/j.jvs.2018.01.071

M3 - Article

C2 - 31159976

AN - SCOPUS:85065792175

VL - 69

SP - 126S-136S

JO - Journal of Vascular Surgery

JF - Journal of Vascular Surgery

SN - 0741-5214

IS - 6

ER -