title: Surgery versus thrombolysis for initial management of acute limb ischaemia.
abstract: BACKGROUND
  Peripheral arterial thrombolysis is technique used in the management of peripheral arterial ischaemia. Much is known about the indications, risks and benefits of thrombolysis. However, it is not known whether thrombolysis works better than surgery in the initial treatment of acute limb ischaemia.
  
  
  OBJECTIVE
  To determine the preferred initial treatment, surgery or thrombolysis, for acute limb ischaemia.
  
  
  METHODS
  For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2013) and CENTRAL (2013, Issue 2).
  
  
  METHODS
  All randomised studies comparing thrombolysis and surgery for the initial treatment of acute limb ischaemia.
  
  
  METHODS
  Each author independently assessed trial quality and extracted data. Agreement was reached by consensus.
  
  
  RESULTS
  Five trials with a total of 1283 participants were included. There was no significant difference in limb salvage or death at 30 days, six months or one year between initial surgery and initial thrombolysis. However, stroke was significantly more frequent at 30 days in thrombolysis participants (1.3%) compared to surgery participants (0%) (Odds ratio (OR) 6.41; 95% confidence interval (CI) 1.57 to 26.22). Major haemorrhage was more likely at 30 days in thrombolysis participants (8.8%) compared to surgery participants (3.3%) (OR 2.80; 95% CI 1.70 to 4.60); and distal embolization was more likely at 30 days in thrombolysis participants (12.4%) compared to surgery participants (0%) (OR 8.35; 95% CI 4.47 to 15.58).Participants treated by initial thrombolysis underwent a less severe degree of intervention (OR 5.37; 95% CI 3.99 to 7.22) and displayed equivalent overall survival compared to initial surgery (OR 0.87; 95% CI 0.61 to 1.25).
  
  
  CONCLUSIONS
  Universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may be associated with a higher risk of ongoing limb ischaemia and haemorrhagic complications including stroke. The higher risk of complications must be balanced against risks of surgery in each person.
authors.affiliation: Leeds Vascular Institute, Leeds General Infirmary, Leeds, UK. david.berridge@leedsth.nhs.uk
authors.forename: David C
authors.initials: DC
authors.lastname: Berridge
authors.forename: David O
authors.initials: DO
authors.lastname: Kessel
authors.forename: Iain
authors.initials: I
authors.lastname: Robertson
mesh_terms: D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D007511:Ischemia / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D007866:Leg / Q000098:blood supply* / Q000601:surgery; D017063:Outcome Assessment, Health Care; D011183:Postoperative Complications / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D020521:Stroke / Q000139:chemically induced; D015912:Thrombolytic Therapy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors