A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb ischemia.

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  • Additional Information
    • Source:
      Publisher: Elsevier Country of Publication: United States NLM ID: 8407742 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1097-6809 (Electronic) Linking ISSN: 07415214 NLM ISO Abbreviation: J Vasc Surg Subsets: MEDLINE
    • Publication Information:
      Publication: <2008-> : New York, NY : Elsevier
      Original Publication: St. Louis, Mo. : Mosby, [c1984-
    • Subject Terms:
      Endovascular Procedures*; Ischemia/*surgery ; Lower Extremity/*blood supply; Acute Disease ; Fibrinolytic Agents/therapeutic use ; Humans ; Ischemia/drug therapy ; Limb Salvage/methods ; Tissue Plasminogen Activator/therapeutic use ; Vascular Surgical Procedures/methods
    • Abstract:
      Background: The initial treatment of patients with acute limb ischemia (ALI) remains undefined. The aim of this article was to compare the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluate the various fibrinolytic agents, endovascular, and pharmacochemical approaches that aim for thrombectomy.
      Methods: PubMed, Embase, and the Cochrane Library were searched for studies on the management of ALI by means of surgical or endovascular recanalization, returning 520 studies. All randomized, controlled trials, nonrandomized prospective, and retrospective studies were included comparing treatment of ALI.
      Results: Twenty-five studies, investigating a total of 4689 patients, were included for meta-analysis spread across nine different comparisons. No differences were found in limb salvage between thrombectomy and thrombolysis. More major vascular events were seen in the thrombolysis group (6.5% compared with 4.4% in the surgically treated group; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87; P = .02; I 2  = 20%). Comparable limb salvage was found for high- and low-dose recombinant tissue plasminogen activator (r-tPA). No significant differences were found in major vascular event between low r-tPA (14%) and high r-tPA (10.5%; P = .13). The 30-day limb salvage rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; 95% CI, 1.26-7.85; P = .01; I 2  = 0%). AngioJet showed more limb salvage at 6 months compared with r-tPa (OR, 2.21; 95% CI, 1.17-4.18; P = .01; I 2  = 0%).
      Conclusions: Both CDT and surgery have comparable limb salvage rates in patients with ALI; however, CDT is associated with a higher risk of hemorrhagic complications. No conclusions can be drawn regarding the risk of hemorrhagic complications regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase. Insufficient data are available to conclude the preference of using a hybrid approach, ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical) thrombectomy systems. Future trials regarding ALI need to be constructed carefully, ensuring comparable study groups, and should follow standardized practices of outcome reporting.
      (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)
    • Contributed Indexing:
      Keywords: Arterial occlusive diseases therapy; Lower extremity blood supply; Mechanical thrombolysis; Thrombectomy; Thrombolysis
    • Accession Number:
      0 (Fibrinolytic Agents)
      EC 3.4.21.68 (Tissue Plasminogen Activator)
    • Publication Date:
      Date Created: 20190730 Date Completed: 20200730 Latest Revision: 20200730
    • Publication Date:
      20231215
    • Accession Number:
      10.1016/j.jvs.2019.05.031
    • Accession Number:
      31353270