title: Endovascular-first approach is not associated with worse amputation-free survival in appropriately selected patients with critical limb ischemia.
abstract: OBJECTIVE
  Endovascular interventions for critical limb ischemia are associated with inferior limb salvage (LS) rates in most randomized trials and large series. This study examined the long-term outcomes of selective use of endovascular-first (endo-first) and open-first strategies in 302 patients from March 2007 to December 2010.
  
  
  METHODS
  Endo-first was selected if (1) the patient had short (5-cm to 7-cm occlusions or stenoses in crural vessels); (2) the disease in the superficial femoral artery was limited to TransAtlantic Inter-Society Consensus II A, B, or C; and (3) no impending limb loss. Endo-first was performed in 187 (62%), open-first in 105 (35%), and 10 (3%) had hybrid procedures.
  
  
  RESULTS
  The endo-first group was older, with more diabetes and tissue loss. Bypass was used more to infrapopliteal targets (70% vs 50%, P = .031). The 5-year mortality was similar (open, 48%; endo, 42%; P = .107). Secondary procedures (endo or open) were more common after open-first (open, 71 of 105 [68%] vs endo, 102 of 187 [55%]; P = .029). Compared with open-first, the 5-year LS rate for endo-first was 85% vs 83% (P = .586), and amputation-free survival (AFS) was 45% vs 50% (P = .785). Predictors of death were age >75 years (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.7-6.6; P = .0007), end-stage renal disease (ESRD) (HR, 3.4; 95% CI, 2.1-5.6; P < .0001), and prior stroke (HR, 1.6; 95% CI, 1.03-2.3; P = .036). Predictors of limb loss were ESRD (HR, 2.5; 95% CI, 1.2-5.4; P = .015) and below-the-knee intervention (P = .041). Predictors of worse AFS were older age (HR, 2.03; 95% CI, 1.13-3.7; P = .018), ESRD (HR, 3.2; 95% CI, 2.1-5.11; P < .0001), prior stroke (P = .0054), and gangrene (P = .024).
  
  
  CONCLUSIONS
  At 5 years, endo-first and open-first revascularization strategies had equivalent LS rates and AFS in patients with critical limb ischemia when properly selected. A patient-centered approach with close surveillance improves long-term outcomes for both open and endo approaches.
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Karan
authors.initials: K
authors.lastname: Garg
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Kaszubski
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Rameen
authors.initials: R
authors.lastname: Moridzadeh
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Caron B
authors.initials: CB
authors.lastname: Rockman
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Adelman
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Thomas S
authors.initials: TS
authors.lastname: Maldonado
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY.
authors.forename: Frank J
authors.initials: FJ
authors.lastname: Veith
authors.affiliation: Division of Vascular and Endovascular Surgery, New York University School of Medicine, New York, NY. Electronic address: firas.mussa@nyumc.org.
authors.forename: Firas F
authors.initials: FF
authors.lastname: Mussa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D016638:Critical Illness; D018572:Disease-Free Survival; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D053208:Kaplan-Meier Estimate; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D016016:Proportional Hazards Models; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality