title: An Endovascular-First Approach to the Treatment of Critical Limb Ischemia Results in Superior Limb Salvage Rates.
abstract: OBJECTIVE
  To evaluate the effect of a shift to a primary endovascular revascularization (ER) strategy for patients presenting with critical limb ischemia (CLI) after a change in staff at our center in 2008 altered our revascularization strategy.
  
  
  METHODS
  Between 2004 and 2012, 344 critically ischemic limbs were treated in 279 patients (mean age 74.0±11.4 years; 179 men) during 546 separate hospital admissions. Limbs were analyzed according to (1) their principal revascularization strategy and (2) their date of presentation [early (2004-2008) or late (2008-2012)].
  
  
  RESULTS
  Compared with the open revascularization (OR) and no revascularization (NR) groups, the ER group had an increased freedom from major amputation (92.3% vs 80.0% OR vs 69.3% NR, p<0.001), reduced hospital stay (15.2 vs OR 31.6 vs NR 25.9 days, p<0.001), intensive care unit (ICU) stay (2.3 vs OR 23.7 vs NR 7.2 hours, p=0.033), and operating time for ER vs OR (157.9 vs 316.8 minutes, respectively; p<0.0001). There was also a significant decrease in limbs requiring minor amputations (23.2% vs OR 29.3% vs NR 37.6%, p=0.041) and mean number of admissions/limb compared to OR (1.5 vs OR 1.9 vs NR 1.5, p=0.007). The late era saw the treatment of a larger number of limbs (223 vs 121) compared with the earlier time period. This institutional shift resulted in increased freedom from major amputation (87.4% vs 74.4%, p<0.01), reduced ICU stay (3.45 vs 16.98 hours, p<0.01), and shorter length of stay (20.9 vs 31.5 days, p<0.01) between the 2 eras, respectively.
  
  
  CONCLUSIONS
  A shift to an endovascular-first treatment strategy is associated with fewer major amputations and shorter length of stay.
authors.affiliation: Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia.
authors.forename: Nedal
authors.initials: N
authors.lastname: Katib
authors.affiliation: Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia.
authors.forename: Shannon D
authors.initials: SD
authors.lastname: Thomas
authors.affiliation: Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia.
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Lennox
authors.affiliation: Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia Adult Cancer Program, Lowy Cancer Research Centre, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia.
authors.forename: Jia-Lin
authors.initials: JL
authors.lastname: Yang
authors.affiliation: Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia Faculty of Medicine, University of New South Wales, Kensington, New South Wales, Australia The Vascular Institute, Prince of Wales Hospital, Sydney, New South Wales, Australia r.varcoe@unsw.edu.au.
authors.forename: Ramon L
authors.initials: RL
authors.lastname: Varcoe
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data; D057510:Endovascular Procedures; D005260:Female; D006801:Humans; D007511:Ischemia / Q000601:surgery*; D007902:Length of Stay / Q000706:statistics & numerical data; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures
keywords: amputation; angioplasty; bypass surgery; critical limb ischemia; endovascular revascularization; limb salvage; peripheral artery disease; stenting