Endovascular-First Treatment Compared With Bypass-First Strategy in Patients With CLI


July 30, 2019—The American Heart Association (AHA) announced that a study of an endovascular-first treatment strategy in treating critical limb ischemia (CLI) was published by Jonathan H. Lin, MD, et al in Circulation: Cardiovascular Quality and Outcomes.

According to the AHA, investigators examined records of more than 16,000 patients (59% male; average age, 71 years) who had undergone either an endovascular procedure first (64%) or open bypass first (36%) for CLI at nongovernment hospitals in California between 2005 and 2013.

The investigators found that during the study period, patients who underwent an endovascular procedure first had a longer period of amputation-free survival compared with those who were first treated with an open surgery–first approach. Additionally, endovascular-first patients were less likely to require a major amputation (below or above the knee_ during the study, slightly more likely to require another procedure or surgery to restore blood flow, and no more likely to die, although at the time of their procedures, many had serious medical conditions such as kidney failure, congestive heart failure, and diabetes.

In the AHA announcement, Dr. Lin commented, “The question has been whether to first offer an open surgery or an endovascular procedure to patients with CLI. Each strategy has its benefits, but it is unclear which one first is optimal and we wanted to gain a better understanding of what the current outcomes were.”

Dr. Lin continued, “The data here suggest that, in the grand scheme of things, an endovascular-first approach is at least not producing a worse result. Regardless, the type of therapy a patient will receive needs to be a decision that patients and their physicians arrive at together. Critical limb ischemia is usually not an emergency and there is time to determine the most appropriate course of therapy.” Dr. Lin is a Surgery Resident in the Department of Surgery at UC Davis Health in Davis, California.

The study was limited by not having information on medical factors (such as the severity of their wounds and whether they had a long and wide enough vein to perform a bypass) that might have influenced whether patients were treated with open surgery or an endovascular procedure. Additionally, the patient population was also limited to specific hospitals in California, noted the AHA.


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