title: Nonrevascularization-based treatments in patients with severe or critical limb ischemia.
abstract: OBJECTIVE
  The aim of this systematic review was to synthesize the existing evidence about various nonrevascularization-based therapies used to treat patients with severe or critical limb ischemia (CLI) who are not candidates for surgical revascularization.
  
  
  METHODS
  We systematically searched multiple databases through November 2014 for controlled randomized and nonrandomized studies comparing the effect of medical therapies (prostaglandin E1 and angiogenic growth factors) and devices (pumps and spinal cord stimulators). We report odds ratios (ORs) and 95% confidence intervals (CIs) of the outcomes of interest pooling data across studies using the random effects model.
  
  
  RESULTS
  We included 19 studies that enrolled 2779 patients. None of the nonrevascularization-based treatments were associated with a significant effect on mortality. Intermittent pneumatic compression (OR, 0.14; 95% CI, 0.04-0.55) and spinal cord stimulators (OR, 0.53; 95% CI, 0.36-0.79) were associated with reduced risk of amputation. A priori established subgroup analyses (combined vs single therapy; randomized vs nonrandomized) were not statistically significant.
  
  
  CONCLUSIONS
  Very low-quality evidence, mainly due to imprecision and increased risk of bias, suggests that intermittent pneumatic compression and spinal cord stimulators may reduce the risk of amputations. Evidence supporting other medical therapies is insufficient.
authors.affiliation: Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn; The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Abd Moain
authors.initials: AM
authors.lastname: Abu Dabrh
authors.affiliation: Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Steffen
authors.affiliation: The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Noor
authors.initials: N
authors.lastname: Asi
authors.affiliation: The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Chaitanya
authors.initials: C
authors.lastname: Undavalli
authors.affiliation: The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Zhen
authors.initials: Z
authors.lastname: Wang
authors.affiliation: The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn.
authors.forename: Mohamed B
authors.initials: MB
authors.lastname: Elamin
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California San Francisco, San Francisco, Calif.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
authors.affiliation: Division of Preventive, Occupational, and Aerospace Medicine, Mayo Clinic, Rochester, Minn; The Knowledge Synthesis Program, the Center for Science of Healthcare Delivery, Mayo Clinic, Rochester, Minn. Electronic address: murad.mohammad@mayo.edu.
authors.forename: Mohammad Hassan
authors.initials: MH
authors.lastname: Murad
mesh_terms: D000671:Amputation, Surgical; D016638:Critical Illness; D006801:Humans; D048228:Intermittent Pneumatic Compression Devices / Q000009:adverse effects; D007511:Ischemia / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D023821:Limb Salvage; D035002:Lower Extremity / Q000098:blood supply*; D016017:Odds Ratio; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D012307:Risk Factors; D012720:Severity of Illness Index; D062187:Spinal Cord Stimulation / Q000009:adverse effects / Q000401:mortality; D016896:Treatment Outcome