Comparison of open and endovascular therapy for infrainguinal acute limb ischemia in the era of percutaneous thrombectomy.

objectiveEndovascular treatment of acute limb ischemia, primarily consisting of catheter-directed thrombolysis (CDT), has been shown to reduce mortality without affecting limb salvage. Percutaneous thrombectomy (PT) devices have expanded endovascular approaches while decreasing thrombolytic use. Although many advocate for an endovascular-first approach, it is unclear which patients would benefit most from each strategy.

methodsWe included adults (18+) who underwent revascularization for infrainguinal acute limb ischemia (January 2016 to December 2023) at a multi-hospital health care system. We compared amputation and mortality after endovascular vs open approaches using logistic regression, Kaplan-Meier curves, and Cox regression.

resultsWe included 315 patients: 145 undergoing an endovascular-first strategy (89 CDT, 51 PT, 5 angioplasty/stent) and 170 undergoing open therapy (132 open thrombectomy, 38 bypass). Patients undergoing endovascular-first treatment were less ischemic, had more prior stenting, and more acute-on-chronic disease. Patients undergoing PT with suction devices were less likely to undergo overnight CDT compared with those with rheolytic devices (21% vs 67%; P = .004). There were no differences in 30-day amputation or mortality, but 30-day reintervention was increased in the endovascular group (adjusted odds ratio, 2.29; 95% confidence interval [CI], 1.06-4.91; P = .03). Three-year amputation rates were not significantly different on univariable or multivariable analysis when comparing the endovascular-first approach with open. PT alone trended toward increased amputation rates compared to open (adjusted hazard ratio [aHR], 1.96; 95% CI, 0.98-3.94; P = .058); however, this was mainly driven by the use of rheolytic devices with an amputation rate of 64% vs 8% in suction devices. Furthermore, those with embolic disease had significantly increased amputation rates (aHR, 2.92; 95% CI, 1.29-6.58; P = .01; P

conclusionsEndovascular-first therapy had increased 3-year amputation in patients with embolic etiology of disease compared with open therapy. We also saw increased 30-day reintervention with endovascular-first therapy when compared with open therapy. CDT had decreased 3-year mortality when compared with open therapy. PT devices had mixed results, indicating that this is a technology in evolution. Newer PT devices are effective at reducing thrombolytic usage, and their amputation and mortality rates were similar to open therapy. An endovascular-first approach to Rutherford 2b ischemia needs further evaluation.