Surgical Vs. Endovascular Revascularization for Chronic Limb Threatening Ischemia: A Meta-Analysis of Randomized Controlled Trials

Background: Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb threatening ischemia (CLTI). The optimal revascularization strategy, in patients who are candidates for surgical bypass and endovascular therapy, remains uncertain, despite recent publication of 2 randomized controlled trials (RCTs). Research Question: Do outcomes differ following surgical and endovascular revascularization for CLTI? Methods: PubMed, Web of Science and the Cochrane Library were searched to identify RCTs comparing outcomes of endovascular versus surgical revascularization for CLTI. Data were pooled for major outcomes including mortality, re-intervention, major amputation, and major adverse cardiovascular events (MACE). Aggregate risk ratios with 95% confidence intervals were calculated using a random-effects model. Results: Three RCTs with 2,627 patients (1,312 endovascular; 1,315 surgical) were included in the meta-analysis. Of these, 1,864 (70.9%) of patients were male and 347 (13.2%) were older than 80 years of age. When comparing endovascular and surgical revascularization, there was no significant difference in 30-day mortality (RR: 0.74 [0.38,1.48], p=0.40), long- term mortality (RR: 1.02 [0.87, 1.19], p=0.82), re-intervention (RR: 1.24 [0.74, 2.07], p=0.41), major amputation, (RR: 1.16 [0.87, 1.54], p=0.31), therapeutic cross-over (RR: 0.92 [0.37, 2.26], p=0.85), or MACE (RR: 1.07 [0.92, 1.26], p=0.37). Conclusion: Current data suggest there is no difference in outcome following endovascular and surgical revascularization for CLTI. A planned patient-level meta-analysis may provide further insight.