SLR - December 2020 - Vincent A. Lefler

A Systematic Review and Meta-Analysis of Endovascular and Surgical Revascularization Techniques in Acute Limb Ischemia

Reference: Veenstra EB, van der Laan MJ, Zeebregts CJ, de Heide EJ, Kater and M, Bokkers RPH. A Systematic Review and Meta-Analysis of Endovascular and Surgical Revascularization Techniques in Acute Limb Ischemia. J Vasc Surg. 2020 Feb;71(2):654-668.

Level of Evidence: Level 1 study

Scientific Literature Review

Reviewed By: Vincent A. Lefler, DPM
Residency Program: McLaren Oakland Hospital – Pontiac, MI

Podiatric Relevance: When dealing with limb salvage situations, vascular perfusion is vital in optimizing patient outcomes. Revascularizations can occur through open intervention or by endovascular methods. Techniques to address acute limb ischemia treatment can be critical on initial evaluation and foot and ankle specialists involved in limb salvage should be aware of the historical and newer treatments options.

Methods: The authors performed a systematic review and meta-analysis of randomized controlled trials and retrospective studies comparing all surgical, thrombolytic, and endovascular thrombectomy strategies.  Inclusion criteria included patients with thromboembolic occlusions in native peripheral artery or vascular grafts. Studies were excluded if it contained insufficient data outcomes, had fewer than 15 patients, or was not written in English. Outcomes included limb salvage after 30 days and major vascular events.  Risk bias assessment was also performed for included studies.

Results: Twenty-five studies were ultimately included in the meta-analysis in which 4689 patients were evaluated. Catheter-driven thrombolysis (CDT) and thrombectomy showed comparable limb salvage rates. Higher major vascular events were noted in thrombolysis and thrombectomy groups (6.5 percent versus 4.4 percent, p = 0.02). Limb salvage rates were comparable in high- and low-dose recombinant tissue plasminogen activator (r-tPA). Major vascular events between low r-tPA and high r-tPA were not significantly different (14 percent versus 10.5 percent, p = 0.13). The 30-day limb salvage rates were statistically higher between r-tPA and streptokinase (79.7 percent vs 60.4 percent, p = 0.01). AngioJet peripheral thrombectomy had a statistically higher limb salvage rate at 6mo in comparison to r-tPA (p = 0.01).

Conclusions: The authors found similar results for 30-day limb salvage with respect to comparing the more traditional thrombectomy versus the more modern approach of CDT. Direct comparisons are more difficult to make due to heterogeneity of different study methods. r-tPA had superior salvage rates when compared to streptokinase, but AngioJet thrombectomy had even higher salvage rates compared to r-tPA at 6mos. Some of the more novel approaches like r-tPA tenecteplase and rheolytical apparatus, such as Rotarex, appear to show promise as well as advantages compared to traditional CDT. However, these findings are from mostly smaller studies and include industry-sponsored research that introduces bias. Ultimately, when consulting vascular surgery services to lend their expertise to challenging ischemic patients, the treatment of acute blockage by CDT or thrombectomy is appropriate. As part of the limb salvage team, foot and ankle surgeons should be aware of newer approaches to treat acute limb ischemia so as to better coordinate patient care.

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