Safety And Efficacy Of An Endovascular-first Approach To Acute Limb Ischemia (ALI)
Olia Poursina, MD, Hector Elizondo, MD, Miguel Montero-Baker, MD, Zachary S. Pallister, MD, Joseph L. Mills, Sr., MD, Jayer Chung, MD, MSc.
Baylor College of Medicine, Houston, TX, USA.
OBJECTIVES: Prior reports suggest that the decreased morbidity/ mortality of endovascular approaches are mitigated by limited technical success rates relative to open/hybrid approaches for acute limb ischmia (ALI). These data fail to include newer technologies that may improve technical success rates. We therefore sought to describe current outcomes of an endovascular-first approach to ALI.
METHODS: Single-center, single-arm, retrospective review of consecutive patients presenting with ALI from 2015-2018. All patients underwent an endovascular-first approach. Technical success, limb salvage, survival, patency, and hospital length of stay were quantified. Cox regression was used to identify predictors of amputation-free survival.
RESULTS: Over three years, 60 patients (39 = male; 65%) with 60 symptomatic limbs presented with ALI (Rutherford Class: I=15 (25%); IIa=23 (38%); IIb=13 (22%); and III=9 (15%). The median age was 65 years (IQR 59, 75). There were 19 (32%) patients who underwent catheter-directed thrombolysis (CDT) only, while 19 (32%) underwent CDT in combination of aspiration and/or rheolytic thrombectomy. Sixteen patients (27%) underwent only aspiration and/or rheolytic thrombectomy. The remainder underwent primary covered stent placement without thrombolytics, or percutaneous thrombectomy. Adjunctive endovascular procedures were performed in 53 (88%), consisting of 25 (42%) balloon angioplasty and stent placements (22 (37%) balloon angioplasties only; and 6 (10%) atherectomies with/without angioplasty and stenting.) Technical success was achieved in 58 (97%), and required open conversion in 2 (3%), consisting of one common femoral endarterectomy and one graft embolectomy. At thirty days, 52 (87%) survived, and 53 (88%) with successful limb salvage. Five patients (8%) underwent four-compartment fasciotomy. Other complications included myocardial infarction/arrhythmia in 7 (12%), acute kidney injury in 10 (17%). There were no major hemorrhagic complications. Median length of stay overall and in the intensive care unit were 9 (IQR 4, 14) days and 2 (IQR 1, 5) days, respectively. At one year, Kaplan-Meier estimates for the following endpoints were: amputation-free survival 58% + 4.2%; survival 73% + 2.7%; limb salvage 75% + 2.6%. Multivariable analysis revealed that a history of prior myocardial infarction independently predicted death/major amputation (HR=2.5, 95% CI 1.03-6.1; p = 0.04.
CONCLUSIONS: Contrary to prior reports, modern endovascular approaches to ALI have high technical success rates. Further prospective evaluations with appropriately powered multi-center cohorts, are warranted to evaluate the efficacy of endovascular versus open approaches to ALI.
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