Treatment options in acute limb ischaemia (ALI) include:
1. Open surgical procedures
- Fogarty catheter thrombectomy/embolectomy
- Thromboendarterectomy (TEA) with patchplasty
- Various bypass procedures
2. Endovascular procedures
- Local direct and pharmacomechanical thrombolysis
- Thrombus aspiration
- Mechanical thrombectomy
- Balloon and stent angioplasty
Open surgical and endovascular revascularisation – outcomes of systematic reviews
A Cochrane review from 2013 with a total of 1283 patients investigated whether open surgical procedures or thrombolysis should be the preferred treatment modality in ALI [1]. No significant differences in limb preservation or death were found at 30 days, 6 months, or 1 year between the groups. Strokes were more frequent in the thrombolysis group than in the surgical group at 30 days (1.3% vs. 0%). The same was true for bleeding complications (8.8% vs. 3.3%) and distal embolisation (12.4% vs. 0%). However, these risks would have to be weighed against the individual surgical risk in each case. The authors therefore concluded that a generally valid recommendation for open surgery or thrombolysis cannot be made.
A later review of 1773 patients enrolled in 6 studies reached similar conclusions regarding short-term outcomes and mortality, amputation rates, and recurrent ischaemia at 12 months [2]. However, since endovascular procedures were associated with lower morbidity, this analysis corroborated an endovascular first-line strategy in ALI.
In a third review from 2016 based on 4 prospective randomised trials as well as 5 further studies, the authors likewise recommended an endovascular first-line strategy in ALI because of equivalent short-term outcomes and lower perioperative morbidity and mortality [3]. However, the authors pointed out the greater need for additional interventions with this strategy: in individual cases, once ALI has been repaired by endovascular means, patients are more likely to be candidates for definitive surgical revascularisation with a better long-term outcome.
Further studies
Taha et al. presented a retrospective comparison of endovascular (154 limbs) and open surgical (326 limbs) revascularisation in lower limb ALI [4]. In the surgical group, 293 thromboembolectomies were performed in addition to 107 bypasses, 67 endarterectomies, and 56 hybrid procedures; the endovascular group underwent 83 catheter-based thrombolyses, 15 pharmacomechanical thrombolyses, and 56 combinations of catheter-based and pharmacomechanical thrombolysis.
Outcomes:
Parameter | Open surgery | Endovascular |
|---|---|---|
Technical success rate | 88.0% | 81.0% |
Wound infection | 9.0% | 0.7% |
Repeat thrombosis | 14.7% | 1.3% |
Amputation rate at 30 days | 13.5% | 6.5% |
Amputation rate at 1 year | 19.6% | 13.0% |
Mortality at 30 days | 13.2% | 5.4% |
Mortality at 1 year | 33.8% | 12.9% |
Mortality at 1 year | 40.5% | 18.7% |
Primary patency rate at 1 year | 57.0% | 51.0% |
Primary patency rate at 2 years | 48.0% | 38% |
When interpreting the results, it must be borne in mind that the surgical patient group more frequently included the treatment of advanced grades of ischaemia of the external iliac artery. In these cases, open surgical revascularisation was superior to endovascular techniques in terms of technical success rate, particularly when the ischaemia was due to underlying stent or bypass failure.
To be able to draw conclusions about morbidity and mortality after embolectomy, Casillas-Berumen et al. used the NSQIP database [5]. The database included 1749 embolectomies performed between 2005 and 2012. The mean age of the patients was 68 years, and almost 48% were men. Iliofemoral-popliteal embolectomies were performed in 1231 (70.4%) patients, popliteo-tibioperoneal embolectomies in 303 (17.3%) patients, and embolectomies at both levels in 215 (12.3%) patients. In 308 patients (17.6%), a fasciotomy was performed concurrently with the embolectomy. Postoperative complications comprised: myocardial infarction/cardiac arrest in 4.7%, pulmonary complications in 16.0%, and wound complications in 8.2% of cases. In 25% of patients, repeat surgery had to be performed within 30 days. Postoperative 30-day mortality was 13.9%.
In an analysis, the authors developed a prognostic model for perioperative mortality. The risk factors included were age > 70 years, male sex, functional dependence, COPD, heart failure, recent myocardial infarction/angina pectoris, chronic renal failure, and steroid therapy. The need for risk stratification is prudent for several reasons, as half of the deceased patients were completely physically dependent, and thus surgical revascularisation must be weighed against palliative end-of-life care. On the other hand, the prediction model can serve to risk-stratify those patients scheduled for surgical embolectomy but who may be better treated by percutaneous embolectomy devices or by catheter-based thrombolysis.