Angioplasty vs. Surgery in Long-Term Critical Ischemia

Critical ischemia is the most advanced form of peripheral arterial disease, and it is characterized by ischemic rest pain and ulcers or gangrene.

Revascularization is obviously positioned as the first-line treatment, and guidelines recommend both possible strategies (surgery or angioplasty) largely based on the findings of the BASIL trial (British Angioplasty versus Surgery in Ischemic Legs).

Read also: “Critical Lower Limb Ischemia Should Be Taken into Account in TAVR”.

Since angioplasty techniques and devices have advanced greatly in the last decade, it remains uncertain whether the BASIL outcomes are still valid in current clinical practice. That uncertainty can be juxtaposed to almost all artery-related fields; we have been wondering for some time now whether the SYNTAX and FREEDOM trials are still valid parameters for coronary arteries.

This multicenter, prospective, observational study enrolled 548 Japanese patients with critical lower limb ischemia. Among them, 197 patients underwent surgical reconstruction and 351 received endovascular treatment. The primary endpoint was amputation-free survival, using propensity score matching.

After adjustment for all variables, amputation-free survival was similar for both strategies (52%; 95% confidence interval [CI]: 43%-60%, y 52%; 95% CI: 44-60%; p = 0.26).

Read also: “Critical ischemia in the lower limbs: Frequent Readmissions show the magnitude of this problem”.

A subsequent analysis identified history of ipsilateral minor amputation, history of revascularization after critical ischemia onset, bilateral critical ischemia, and Wound, Ischemia, and foot Infection (WIfI) classification W-3 as the more favorable factors for surgical treatment. On the other hand, diabetes, renal failure, anemia, history of nonadherence to medical treatment, and contralateral major amputation favored angioplasty.

Conclusion

Amputation-free survival was similar between both revascularization strategies in the overall population with critical lower limb ischemia. However, the subsequent interaction analysis suggested that certain subgroups would benefit more from one treatment than the other.

Editorial

Major tissue loss and infection (both of which are predictors for delayed wound healing and amputation) require abundant blood flow for limb salvage. In this respect, surgery might be better at providing sufficient blood flow supply.

The Rutherford classification was identified as a worse event predictor than the WIfI classification. This might be due to the fact that the former is not so accurate in grading wound severity. The WIfI classification is more informative than the Rutherford classification at least in selecting revascularization strategies.

Angioplasty wins in patients with a higher number of systemic comorbidities (such as diabetes, renal failure, anemia, etc.), for whom the surgical risk is higher. Surgery pays the price for its invasiveness.

Original title: Three-Year Outcomes of Surgical Versus Endovascular Revascularization for Critical Limb Ischemia. The SPINACH Study (Surgical Reconstruction Versus Peripheral Intervention in Patients with Critical Limb Ischemia).

Reference: Osamu Iida et al. Circ Cardiovasc Interv. 2017 Dec;10(12).

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