Contemporary Practice Patterns and Outcomes of Endovascular Revascularization of Acute Limb Ischemia

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

OBJECTIVE

Endovascular 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.

METHODS

We 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.

RESULTS

We 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; Pinteraction = .02) with any endovascular-first strategy, when compared with open therapy. Endovascular-first patients had decreased mortality on univariable analysis (16% vs 37%; log-rank = .004) but not multivariable analysis (aHR, 0.60; 95% CI, 0.32-1.13; P = .12). When separated by endovascular modality, CDT had decreased mortality compared with open (aHR, 0.41; 95% CI, 0.18-0.93; P = .033), whereas PT did not (aHR, 1.05; 95% CI, 0.47-2.35; P = .91). Although effect of treatment modality on outcomes was not moderated by Rutherford classification, only 22 patients underwent endovascular-first treatment for Rutherford 2b ischemia.

CONCLUSIONS

Endovascular-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.

Misdiagnosis of Acute Limb Ischemia from Non-Vascular Specialists Results in a Delayed Presentation and Negatively Affects Patients' Outcomes

BACKGROUND/OBJECTIVES

Acute Limb Ischemia (ALI) is a vascular emergency which is accompanied by a significant risk of limb loss or even death. Rapid restoration of arterial perfusion using surgical and/or endovascular techniques is crucial for limb salvage. Undeniably, an accurate and prompt diagnosis is the first step to improve patient prognosis. The typical clinical presentation is not always present and the variety of symptoms may result in non-vascular specialists missing the diagnosis.

METHODS

In this single-center retrospective descriptive study, we reviewed all patients hospitalized between January 2018 and January 2024 for ALI. Patients who were initially misdiagnosed, causing a delayed diagnosis > 24 h, and who therefore did not receive timely treatment, were identified. Moreover, patients with a timely diagnosis of ALI who were treated in our institution during the same time period were collected.

RESULTS

Among 280 ALI patients, 14 were initially misdiagnosed. The median time from initial symptoms to definite diagnosis was 38.8 days (range 1.5-365). Several specialties such as orthopedic surgeons, neurologists, and general practitioners were involved in patients' initial assessment. Three patients underwent primary amputation due to irreversible ALI, while nine underwent revascularization and one conservative treatment. Thirty-day limb salvage rate was 9/14 and thirty-day mortality was observed in one patient. Secondary interventions were needed in 65% of these cases. Patients with a delayed ALI diagnosis, when compared to those with a timely diagnosis, presented a significantly lower limb salvage rate (65% vs. 89%, p-value = 0.02) and a significantly higher rate of reinterventions (65% vs. 18%, p-value < 0.001).

CONCLUSIONS

Many patients with ALI are primarily referred to non-vascular specialties. Misdiagnosed and mistreated ALI negatively affects outcomes.