A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

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A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. / Almasri, Jehad; Adusumalli, Jayanth; Asi, Noor; Lakis, Sumaya; Alsawas, Mouaz; Prokop, Larry J; Bradbury, Andrew; Kolh, Philippe; Conte, Michael S; Murad, M Hassan.

In: Journal of Vascular Surgery, Vol. 68, No. 2, 08.2018, p. 624-633.

Research output: Contribution to journalReview articlepeer-review

Harvard

Almasri, J, Adusumalli, J, Asi, N, Lakis, S, Alsawas, M, Prokop, LJ, Bradbury, A, Kolh, P, Conte, MS & Murad, MH 2018, 'A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia', Journal of Vascular Surgery, vol. 68, no. 2, pp. 624-633. https://doi.org/10.1016/j.jvs.2018.01.066

APA

Almasri, J., Adusumalli, J., Asi, N., Lakis, S., Alsawas, M., Prokop, L. J., Bradbury, A., Kolh, P., Conte, M. S., & Murad, M. H. (2018). A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. Journal of Vascular Surgery, 68(2), 624-633. https://doi.org/10.1016/j.jvs.2018.01.066

Vancouver

Author

Almasri, Jehad ; Adusumalli, Jayanth ; Asi, Noor ; Lakis, Sumaya ; Alsawas, Mouaz ; Prokop, Larry J ; Bradbury, Andrew ; Kolh, Philippe ; Conte, Michael S ; Murad, M Hassan. / A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. In: Journal of Vascular Surgery. 2018 ; Vol. 68, No. 2. pp. 624-633.

Bibtex

@article{9f4776210df9427a96f67fe5527ee08a,
title = "A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia",
abstract = "BACKGROUND: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.METHODS: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.RESULTS: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.CONCLUSIONS: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.",
keywords = "Amputation, Blood Vessel Prosthesis Implantation/adverse effects, Chronic Disease, Clinical Decision-Making, Drug-Eluting Stents, Endovascular Procedures/adverse effects, Evidence-Based Medicine, Graft Occlusion, Vascular/etiology, Humans, Ischemia/diagnosis, Limb Salvage, Patient Selection, Peripheral Arterial Disease/diagnosis, Risk Factors, Saphenous Vein/physiopathology, Time Factors, Treatment Outcome",
author = "Jehad Almasri and Jayanth Adusumalli and Noor Asi and Sumaya Lakis and Mouaz Alsawas and Prokop, {Larry J} and Andrew Bradbury and Philippe Kolh and Conte, {Michael S} and Murad, {M Hassan}",
note = "Copyright {\textcopyright} 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.",
year = "2018",
month = aug,
doi = "10.1016/j.jvs.2018.01.066",
language = "English",
volume = "68",
pages = "624--633",
journal = "Journal of Vascular Surgery",
issn = "0741-5214",
publisher = "Elsevier",
number = "2",

}

RIS

TY - JOUR

T1 - A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia

AU - Almasri, Jehad

AU - Adusumalli, Jayanth

AU - Asi, Noor

AU - Lakis, Sumaya

AU - Alsawas, Mouaz

AU - Prokop, Larry J

AU - Bradbury, Andrew

AU - Kolh, Philippe

AU - Conte, Michael S

AU - Murad, M Hassan

N1 - Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

PY - 2018/8

Y1 - 2018/8

N2 - BACKGROUND: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.METHODS: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.RESULTS: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.CONCLUSIONS: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

AB - BACKGROUND: The optimal strategy for revascularization in infrainguinal chronic limb-threatening ischemia (CLTI) remains debatable. Comparative trials are scarce, and daily decisions are often made using anecdotal or low-quality evidence.METHODS: We searched multiple databases through May 7, 2017, for prospective studies with at least 1-year follow-up that evaluated patient-relevant outcomes of infrainguinal revascularization procedures in adults with CLTI. Independent pairs of reviewers selected articles and extracted data. Random-effects meta-analysis was used to pool outcomes across studies.RESULTS: We included 44 studies that enrolled 8602 patients. Periprocedural outcomes (mortality, amputation, major adverse cardiac events) were similar across treatment modalities. Overall, patients with infrapopliteal disease had higher patency rates of great saphenous vein graft at 1 and 2 years (primary: 87%, 78%; secondary: 94%, 87%, respectively) compared with all other interventions. Prosthetic bypass outcomes were notably inferior to vein bypass in terms of amputation and patency outcomes, especially for below knee targets at 2 years and beyond. Drug-eluting stents demonstrated improved patency over bare-metal stents in infrapopliteal arteries (primary patency: 73% vs 50% at 1 year), and was at least comparable to balloon angioplasty (66% primary patency). Survival, major amputation, and amputation-free survival at 2 years were broadly similar between endovascular interventions and vein bypass, with prosthetic bypass having higher rates of limb loss. Overall, the included studies were at moderate to high risk of bias and the quality of evidence was low.CONCLUSIONS: There are major limitations in the current state of evidence guiding treatment decisions in CLTI, particularly for severe anatomic patterns of disease treated via endovascular means. Periprocedural (30-day) mortality, amputation, and major adverse cardiac events are broadly similar across modalities. Patency rates are highest for saphenous vein bypass, whereas both patency and limb salvage are markedly inferior for prosthetic grafting to below the knee targets. Among endovascular interventions, percutaneous transluminal angioplasty and drug-eluting stents appear comparable for focal infrapopliteal disease, although no studies included long segment tibial lesions. Heterogeneity in patient risk, severity of limb threat, and anatomy treated renders direct comparison of outcomes from the current literature challenging. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision making in CLTI.

KW - Amputation

KW - Blood Vessel Prosthesis Implantation/adverse effects

KW - Chronic Disease

KW - Clinical Decision-Making

KW - Drug-Eluting Stents

KW - Endovascular Procedures/adverse effects

KW - Evidence-Based Medicine

KW - Graft Occlusion, Vascular/etiology

KW - Humans

KW - Ischemia/diagnosis

KW - Limb Salvage

KW - Patient Selection

KW - Peripheral Arterial Disease/diagnosis

KW - Risk Factors

KW - Saphenous Vein/physiopathology

KW - Time Factors

KW - Treatment Outcome

U2 - 10.1016/j.jvs.2018.01.066

DO - 10.1016/j.jvs.2018.01.066

M3 - Review article

C2 - 29804736

VL - 68

SP - 624

EP - 633

JO - Journal of Vascular Surgery

JF - Journal of Vascular Surgery

SN - 0741-5214

IS - 2

ER -