A comparison between open and endovascular repair in the treatment of critical limb ischemia

Aim. The aim of this study was to prospectively compare the results of open and endovascular surgery in the management of chronic critical limb ischemia Methods. From January 2005 to December 2007, 34 consecutive patients with chronic critical limb ischemia underwent endovascular procedures (group 1). Data concerning these patients were prospectively collected in a dedicated database and were compared to 39 patients with similar clinical and anatomical status undergoing surgical bypass during the period 2004-2005 (group 2). Early results in terms of technical success and conversion to open repair for patients in group 1 and of mortality, thrombosis and amputation rates for both groups were analyzed and compared by means of χ2 and Fisher tests. Follow-up results were analyzed in terms of survival, primary and secondary patency and limb salvage by means of Kaplan-Meyer curves and comparison performed with log-rank test. Results. In group 1, the rate of technical success was 91.2% (31/34). Thirty-one patients underwent recanalization of an occluded superficial femoral artery; in 10 cases with isolated percutaneous transluminal angioplasty (PTA) and in the remaining 21 with stent placement. In 26 patients (84%) a below knee endovascular procedure (popliteal and/or tibial PTA) was concomitantly performed. Two patients (5.9%) required immediate conversion to surgical bypass and 1 patient was medically managed following failed endovascular intervention. In the patients of group 2, open surgical repair consisted of femoral-below knee popliteal bypass in 32 cases (82%) and femoral-tibial bypass in 7 cases (18%). There were no perioperative deaths or amputations in either group. The rate of perioperative thrombosis was 3% in group 1 (1 case) and 15.4% in group 2 (6 cases) (P=0.07). No other major perioperative complications occurred in either group.Median duration of follow-up was 13 months (range 1-48). Results in terms of 12-month survival rate were significantly better in group 2 than in group 1 (89.1% and 62.5%, respectively; P=0.01, log rank 5.9) and there was a trend towards improved primary patency rates in group 2 at 12 months (67.9% in group 2 and 58.9% in group 1). There were no significant differences between the two groups in terms of secondary patency and limb salvage rates (67.9% and 96.8% in group 1 and 81.9% and 88.2% in group 2, respectively, P=NS). Conclusion. Critical limb ischemia due to complex lesions of the infrainguinal vessels can be safely treated with open or endovascular surgery. In our experience, an initial endovascular approach provides satisfactory perioperative and early results, and during intermediate follow-up maintains good patency and excellent limb salvage rates comparable to surgical bypass.