Outcomes of open and endovascular interventions in patients with chronic limb threatening ischemia.
OBJECTIVES
Widespread adoption of endovascular therapy for the treatment of chronic limb-threatening ischemia has transformed the field of vascular surgery. In this modern era, we aimed to define where open surgical interventions are of greatest benefit for limb salvage.


METHODS
Patients who underwent interventions for chronic limb-threatening ischemia were identified in the vascular-targeted lower extremity National Surgical Quality Improvement Program database for open surgical interventions (OPEN) and endovascular surgical interventions (ENDO) from 2011 to 2017. Patients were further stratified based on the criteria of chronic limb-threatening ischemia (rest pain or tissue loss), and the location of the diseased arteries (femoropopliteal or tibioperoneal). The main outcomes measured included 30-day mortality, amputation, and major adverse cardiovascular events.


RESULTS
A total of 17,193 patients were revascularized for chronic limb-threatening ischemia: 10,532 were OPEN and 6661 were ENDO. OPEN had higher 30-day mortality, major adverse cardiovascular events, pulmonary, renal dysfunction, and wound complications. However, OPEN resulted in significantly lower 30-day major amputation (3.8% vs. 5.0%, odds ratio (OR): 0.83 [0.72-0.97], P = .018). Subgroup analysis revealed a higher mortality rate in OPEN was observed only in tibioperoneal intervention for tissue loss. Major adverse cardiovascular event was higher in OPEN for most subgroups. OPEN for patients with tissue loss had significantly lower amputation rate than ENDO in both femoropopliteal and tibioperoneal subgroups (3.7% vs. 5.1%, OR: 0.76 [0.59-0.98], P = .036, and 4.7% vs. 6.6%, OR: 0.74 [0.57-0.96], P = .024, respectively). The benefit of open surgery in reducing the amputation rate was not seen in patients with rest pain.


CONCLUSIONS
Open surgical intervention is associated with significantly better limb salvage than endovascular intervention in patients with tissue loss. Surgical options should be given more emphasis as the first-line option in this cohort of patients unless the cardiopulmonary risk is prohibitive.
['Lee|K Benjamin|KB|https://orcid.org/0000-0003-2938-9227', 'Macsata|Robyn A|RA|', 'Lala|Salim|S|', 'Sparks|Andrew D|AD|', 'Amdur|Richard L|RL|', 'Ricotta|John J|JJ|', 'Sidawy|Anton N|AN|', 'Nguyen|Bao-Ngoc|BN|']
D000368:Aged D000369:Aged, 80 and over D000671:Amputation D002908:Chronic Disease D016208:Databases, Factual D057510:Endovascular Procedures D005260:Female D006801:Humans D007511:Ischemia D023821:Limb Salvage D008297:Male D008875:Middle Aged D058729:Peripheral Arterial Disease D011183:Postoperative Complications D012189:Retrospective Studies D018570:Risk Assessment D012307:Risk Factors D013997:Time Factors D016896:Treatment Outcome D014481:United States D058017:Vascular Grafting D014945:Wound Healing
endovascular Chronic limb threatening ischemia rest pain tissue loss bypass