Objective Endovascular interventions for critical limb ischemia are associated with inferior limb salvage (LS) rates in most randomized trials and large series. This study examined the long-term outcomes of selective use of endovascular-first (endo-first) and open-first strategies in 302 patients from March 2007 to December 2010. Methods Endo-first was selected if (1) the patient had short (5-cm to 7-cm occlusions or stenoses in crural vessels); (2) the disease in the superficial femoral artery was limited to TransAtlantic Inter-Society Consensus II A, B, or C; and (3) no impending limb loss. Endo-first was performed in 187 (62%), open-first in 105 (35%), and 10 (3%) had hybrid procedures. Results The endo-first group was older, with more diabetes and tissue loss. Bypass was used more to infrapopliteal targets (70% vs 50%, P =.031). The 5-year mortality was similar (open, 48%; endo, 42%; P =.107). Secondary procedures (endo or open) were more common after open-first (open, 71 of 105 [68%] vs endo, 102 of 187 [55%]; P =.029). Compared with open-first, the 5-year LS rate for endo-first was 85% vs 83% (P =.586), and amputation-free survival (AFS) was 45% vs 50% (P =.785). Predictors of death were age >75 years (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.7-6.6; P =.0007), end-stage renal disease (ESRD) (HR, 3.4; 95% CI, 2.1-5.6; P <.0001), and prior stroke (HR, 1.6; 95% CI, 1.03-2.3; P =.036). Predictors of limb loss were ESRD (HR, 2.5; 95% CI, 1.2-5.4; P =.015) and below-the-knee intervention (P =.041). Predictors of worse AFS were older age (HR, 2.03; 95% CI, 1.13-3.7; P =.018), ESRD (HR, 3.2; 95% CI, 2.1-5.11; P <.0001), prior stroke (P =.0054), and gangrene (P =.024). Conclusions At 5 years, endo-first and open-first revascularization strategies had equivalent LS rates and AFS in patients with critical limb ischemia when properly selected. A patient-centered approach with close surveillance improves long-term outcomes for both open and endo approaches.
ASJC Scopus subject areas
- Cardiology and Cardiovascular Medicine