Original title: Comparative effectiveness of endovascular andsurgical revascularization for patients with peripheralartery disease and critical limb ischemia: Systematicreview of revascularization in critical limb ischemia. Reference: W Schuyler Jones, et al. (Am Heart J 2014; 167:167:489-498.e7)

Lower limbs critical ischemia is the most severe condition of PAD. The morbidity, mortality and costs related thereto are well documented; however, the method of choice to prevent amputation, death and preserve functional capacity is not yet defined. 

This paper reviewed the relevant studies published from 1995 to 2012, in which endovascular technique was compared with surgery regarding death, cardiovascular events, amputation, quality of life, patency of the case treated and reintervention. Both techniques in 23 works were compared totalling 12,779 patients with critical lower limb ischemia. One of the studies was randomized, and 22 were observational. The average age of the patients ranged between 61 and 83 years, the number of patients evaluated ranged from 73 to 4,929, and the length of study was 30 days to 60 months. The quality of the studies evaluated was also a variable.

In terms of all-cause mortality, no significant superiority of the endovascular procedure at 6 months was found, but this disappeared after two years, being the same in both procedures. No difference was found between the procedures in assessing long-term amputation. Nine studies assessed vessel patency, being higher in the endovascular procedure. One study evaluated the time to healing chronic wounds, resulting this lower in the surgical procedure. The research also assessed other variables such as age, anatomical factors, tissue loss and technique used, with varying results without statistical significance. None of the studies considered subgroups by sex, race, smoking or the presence of renal insufficiency.

Conclusion

The conclusion reached in the present meta-analysis is that the evidence available at the time for the treatment of critical lower limb ischemia is limited since it is based on few studies, most of them non-randomized, not superiority lies between angioplasty and surgery.

Editorial comment

The only important randomized study is the BASIL, which recruited patients more than 10 years ago to compare both techniques, however, in the endovascular branch, current technologies in terms of stents, balloons, etc., were not used. Even so, based on this information, in 2011 the existing guidelines were updated, indicating that both procedures were similar. Randomized studies are needed to compare both techniques using current technologies.

Courtesy of Alfonso Francisco Balaguer Quiroga MD
Interventional Cardiologist.
International Clinic. Lima, Peru.

Dr. Alfonso Francisco Balaguer Quiroga