Original title: Comparative effectiveness of endovascular and surgical revascularization for patients with peripheral artery disease and critical limb ischemia. Reference: W. Schuyler Jones et al. American Heart Journal 2014. Epub ahead of print.

Critical limb ischemia is the most severe condition affecting patients with peripheral vascular disease. Mortality, morbidity, and costs associated with this condition are well documented, but the optimal treatment that can preserve the lower limb, improve functional capacity, and decrease mortality is not clear yet. In the latest update of the guidelines ACC / AHA there is not clear recommendation about this.

This meta-analysis included 23 studies (one randomized and 22 observational ) to compare mortality, amputation-free survival, ulcer healing , quality of life, repeat revascularization and vessel patency in 12779 patients with critical limb ischemia who received surgical or endovascular revascularization. No differences in overall mortality at one year, two years or beyond the 3 years between the two strategies were observed as in the rate of amputation of the affected lower limb (OR 1.06, 0.70-1.59). The primary patency rate favored the endovascular treatment (OR 0.63, 0.46 to 0.86), observing something similar with secondary permeability at one year and after 2 and 3 years (OR 0.49, 0.28 to 0.85). Subintimal angioplasty was associated with a nonsignificant trend toward worse outcomes than standard angioplasty.

Conclusion

The available evidence regarding the treatment of patients with critical limb ischemia is limited mostly to observational studies, found only in the literature, one study that randomized these patients to surgery or angioplasty. Is not surprising that significant differences were into hard points such as mortality or amputation rate, but obviously further studies are needed. 

Editorial comment

There was only one study that randomized patients with critical ischemia either to one or two strategies; (Bypass versus angioplasty in severe ischemia of the leg (BASIL) Lancet. 2005) enrolled patients over 10 years ago and in fact did not allow stenting in endovascular strategy. The subsequent introduction of multiple devices makes the results of this study not very useful today for clinical decision-making. Recently, the National Institutes of Health announced it will finance the BEST study (Best Endovascular versus best Surgical Therapy for Critical Limb Ischemia) that will answer several questions, while the strategy should be decided according to the experience of each center.

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