PMID- 38232807 OWN - NLM STAT- MEDLINE DCOM- 20240226 LR - 20240226 IS - 1879-1913 (Electronic) IS - 0002-9149 (Linking) VI - 214 DP - 2024 Mar 1 TI - An Endovascular- Versus a Surgery-First Revascularization Strategy for Chronic Limb-Threatening Ischemia: A Meta-Analysis of Randomized Controlled Trials. PG - 149-156 LID - S0002-9149(24)00039-0 [pii] LID - 10.1016/j.amjcard.2024.01.007 [doi] AB - Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results. We conducted a trial-level meta-analysis to compare the outcomes between endovascular-first and surgery-first strategies for revascularization. PubMed, Web of Science, and the Cochrane Library were searched to identify RCTs comparing the outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RRs) with 95% confidence intervals were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using the pooled aggregated data from published curves, with their corresponding hazard ratios (HRs) and 95% confidence intervals reported for up to 5 years of follow-up. A total of 3 RCTs with 2,627 patients (1,312 endovascular-first and 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 patients (70.9%) were men and 347 (13.2%) were older than 80 years. Comparing the endovascular-first and surgery-first approaches, there was no significant difference in the overall (HR 0.92 [0.83 to 1.01], p = 0.09) or amputation-free survival (HR 0.98 [0.92 to 1.03], p = 0.42), reintervention (RR 1.24 [0.74 to 2.07], p = 0.41), major amputation, (RR 1.16 [0.87 to 1.54], p = 0.31), or therapeutic crossover (RR 0.92 [0.37 to 2.26], p = 0.85). In conclusion, data from available RCTs suggest that there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight. CI - Copyright (c) 2024 Elsevier Inc. All rights reserved. FAU - Mufarrih, Syed Hamza AU - Mufarrih SH AD - Department of Medicine, University of Kentucky, Bowling Green, Kentucky. Electronic address: hamzamufarrih@live.com. FAU - Khan, Mohammad Saud AU - Khan MS AD - Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky. FAU - Qureshi, Nada Qaisar AU - Qureshi NQ AD - Department of Medicine, University of Kentucky, Bowling Green, Kentucky. FAU - Akbar, Muhammad Shoaib AU - Akbar MS AD - Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky. FAU - Kazimuddin, Mohammed AU - Kazimuddin M AD - Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Bowling Green, Kentucky. FAU - Goldsweig, Andrew M AU - Goldsweig AM AD - Division of Cardiovascular Medicine, Department of Medicine, Baystate Medical Center, Springfield, Massachusetts. FAU - Goodney, Philip P AU - Goodney PP AD - Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire. FAU - Aronow, Herbert D AU - Aronow HD AD - Division of Cardiovascular Medicine, Department of Medicine, Henry Ford Health, Detroit and Michigan State University College of Human Medicine, East Lansing, Michigan. Electronic address: haronow1@hfhs.org. LA - eng PT - Journal Article PT - Meta-Analysis DEP - 20240115 PL - United States TA - Am J Cardiol JT - The American journal of cardiology JID - 0207277 SB - IM MH - Male MH - Humans MH - Female MH - Chronic Limb-Threatening Ischemia MH - Risk Factors MH - *Endovascular Procedures/methods MH - Ischemia/surgery MH - *Peripheral Arterial Disease MH - Randomized Controlled Trials as Topic MH - Treatment Outcome MH - Retrospective Studies MH - Chronic Disease OTO - NOTNLM OT - CLTI OT - chronic limb-threatening ischemia OT - critical limb ischemia OT - endovascular OT - endovascular versus surgical OT - surgical COIS- Declaration of competing interest Dr. Aronow reports serving on the Advisory Board for Medtronic and providing consultancy services for Philips. Dr. Goodney is a committee member contributing to the forthcoming patient-level meta-analysis of BEST-CLI and BASIL-2. The remaining authors have no competing interest to declare. EDAT- 2024/01/18 00:42 MHDA- 2024/02/26 06:45 CRDT- 2024/01/17 19:11 PHST- 2023/12/16 00:00 [received] PHST- 2024/01/07 00:00 [accepted] PHST- 2024/02/26 06:45 [medline] PHST- 2024/01/18 00:42 [pubmed] PHST- 2024/01/17 19:11 [entrez] AID - S0002-9149(24)00039-0 [pii] AID - 10.1016/j.amjcard.2024.01.007 [doi] PST - ppublish SO - Am J Cardiol. 2024 Mar 1;214:149-156. doi: 10.1016/j.amjcard.2024.01.007. Epub 2024 Jan 15.