PMID- 31159976 OWN - NLM STAT- MEDLINE DCOM- 20191118 LR - 20191118 IS - 1097-6809 (Electronic) IS - 0741-5214 (Linking) VI - 69 IP - 6S DP - 2019 Jun TI - A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. PG - 126S-136S LID - S0741-5214(19)30983-8 [pii] LID - 10.1016/j.jvs.2018.01.071 [doi] 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. CI - Copyright (c) 2019. Published by Elsevier Inc. FAU - Almasri, Jehad AU - Almasri J AD - Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn. FAU - Adusumalli, Jayanth AU - Adusumalli J AD - Division of General Internal Medicine, Mayo Clinic, Rochester, Minn. FAU - Asi, Noor AU - Asi N AD - Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn. FAU - Lakis, Sumaya AU - Lakis S AD - Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn. FAU - Alsawas, Mouaz AU - Alsawas M AD - Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn. FAU - Prokop, Larry J AU - Prokop LJ AD - Mayo Clinic Libraries, Mayo Clinic, Rochester, Minn. FAU - Bradbury, Andrew AU - Bradbury A AD - Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom. FAU - Kolh, Philippe AU - Kolh P AD - Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liege, Liege, Belgium. FAU - Conte, Michael S AU - Conte MS AD - Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, Calif. FAU - Murad, M Hassan AU - Murad MH AD - Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minn; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minn. Electronic address: murad.mohammad@mayo.edu. LA - eng PT - Journal Article PT - Meta-Analysis PT - Research Support, Non-U.S. Gov't PT - Systematic Review DEP - 20190528 PL - United States TA - J Vasc Surg JT - Journal of vascular surgery JID - 8407742 SB - IM MH - Blood Vessel Prosthesis MH - *Blood Vessel Prosthesis Implantation/adverse effects/instrumentation/mortality MH - Chronic Disease MH - *Endovascular Procedures/adverse effects/instrumentation/mortality MH - Graft Occlusion, Vascular/etiology/physiopathology MH - Humans MH - Ischemia/diagnosis/mortality/physiopathology/*therapy MH - Limb Salvage MH - Peripheral Arterial Disease/diagnosis/mortality/physiopathology/*therapy MH - Progression-Free Survival MH - Risk Assessment MH - Risk Factors MH - Saphenous Vein/physiopathology/*transplantation MH - Stents MH - Time Factors MH - Vascular Patency OTO - NOTNLM OT - Bypass surgery OT - Critical limb ischemia OT - Endovascular treatment OT - Revascularization OT - Severe limb ischemia EDAT- 2019/06/05 06:00 MHDA- 2019/11/19 06:00 CRDT- 2019/06/05 06:00 PHST- 2017/08/25 00:00 [received] PHST- 2018/01/02 00:00 [accepted] PHST- 2019/06/05 06:00 [entrez] PHST- 2019/06/05 06:00 [pubmed] PHST- 2019/11/19 06:00 [medline] AID - S0741-5214(19)30983-8 [pii] AID - 10.1016/j.jvs.2018.01.071 [doi] PST - ppublish SO - J Vasc Surg. 2019 Jun;69(6S):126S-136S. doi: 10.1016/j.jvs.2018.01.071. Epub 2019 May 28.