SS02 - Endovascular-first Revascularization Is as Safe and Efficacious as Open-first Revascularization for Acute Limb Ischemia (ALI)

Objectives: The independent effect of initial revascularization strategy (open surgery-first [OS] versus endovascular-first [EV]) on acute limb ischemia (ALI) outcomes remains uncertain due to lack of data directly comparing modalities. We aim to evaluate amputation-free survival (AFS) following OS versus EV and identify clinical factors associated with outcome.

Methods: We conducted a two-center retrospective cohort study of adults presenting with ALI. Patients were defined by initial therapy: OS (surgical thrombectomy ± endarterectomy or bypass) or EV (catheter-directed thrombolysis, rheolytic, vacuum-assisted aspiration thrombectomy each + adjunctive angioplasty, stenting, atherectomy). Outcomes included major amputation, mortality, and AFS (at 90 days and last follow-up.) Descriptive statistics, univariable and multivariable Cox proportional hazards modeling were utilized.

Results: Over nine years, we identified 367 patients (394 legs- 27 [7.4%] bilateral; median age 65.5 years [IQR 56–75]; 55.3% male; median follow-up 614 days [IQR 172–1223]). Clinical profiles differed, with EV (N=186) more often having chronic atherosclerotic risk factors and OS (N=181) more frequently with emboli. At 90 days, outcomes in EV versus OS were: major amputation 12.4% vs 15.9% (p=.32), mortality in 10.5% vs 15.4% (p=.16), and AFS 78.9% vs 71.4% (p=.08; Figure 1). Re-interventions were more frequent with EV (46.6% vs 26.4%; p < 0.001). At last follow-up, EV was associated with improved AFS (mean 4.9 vs 3.6 years; p=.01); and survival (6.2 vs 4.7 years; log-rank p=0.003); with no difference in long-term limb loss. Multivariable Cox regression showed ischemia severity (Rutherford class; HR 2.26 95% CI 1.48-3.48, p < 0.001) and congestive heart failure (HR 1.58, 95% CI 1.00–2.49, p = .04) increased the risk of major amputation/death. Subgroup analysis showed no early AFS differences by sex (23% vs 28%, p=.28) or by embolic versus thrombotic presentation (25% vs 25%, p=.93). Thrombolysis alone offered no early advantage (22% vs 27%, p=.28), whereas vacuum-assisted aspiration thrombectomy was associated with fewer early failures (16% vs 30%, p=.004), aligning with multivariable results. In contrast, rheolytic thrombectomy showed no detectable benefit (31% vs 25%, p=.40).

Conclusions: In our large, contemporary cohort, EV and OS are similarly safe and efficacious, albeit with more frequent re-interventions for EV. Rutherford class shows the largest effect upon AFS and increases the hazard of major amputation/death by more than two-fold. Our data show equipoise between current open and endovascular revascularization, suggesting that future multi-center, randomized study may be required to ascertain comparative effectiveness, and optimize specific revascularization strategies depending upon presentation.