[Comparing the results of endovascular interventions and bypass surgery in patients with chronic lower limb ischemia (literature review)].

Abstract

Background: Current strategies of treatment for lower limb chronic ischemia continue to be controversial. Previously performed reviews on this subject had no rigorous restrictions in selection of inclusion criteria for patients with the pathology involved.

Objective: The purpose of our study was to compare the results of endovascular interventions and bypass surgery in patients with lower limb chronic ischemia.

Methods: We performed a detailed retrieval in several databases prior to 2019, taking into consideration prospective studies with the duration of not less than 2 years aimed at comparing the results of procedures of revascularization of the infrarenal region in adults with lower limb chronic ischemia. Independent pairs of reviewers selected the articles from which the necessary data were then extracted.

Results: Our meta-analysis included 17 studies comprising a total of 22 369 patients. In the overall population, endovascular treatment decreased the risk of 30-day mortality (HR=0.73, 95% CI 0.59-0.90, p=0.004). Cases of amputation of lower extremity within 30 days after vascular reconstructions were reported in 7 articles, with no statistically significant difference between the results of endovascular and open surgical interventions for this criterion (HR=0.67, 95% CI 0.67-1.10, p=0.113). Early postoperative complications concerning cardiovascular and cerebrovascular systems were described in 9 articles, with infections of postoperative wounds reported in 8 publications. The incidence of postoperative complications was statistically higher in patients after bypass surgery as compared with the group after endovascular interventions. The overall survival rate in the remote postoperative period: combined results of 12 studies demonstrated that patients after endured endovascular interventions had had significantly higher risk of remote death than patients after bypass surgery (HR=0.78, 95% CI 0.67-0.92; p=0.002). It was revealed that the difference of the results after autovenous bypass grafting was more significant (HR=1.01; 95% CI 0.87-1.22, p=0.0001). As to infrapopliteal lesions, endovascular and bypass interventions ensured a comparable survival rate (HR=1.12, 95% CI 0.83-141; p=0.12). Nevertheless, we discovered that endovascular interventions were associated with significantly elevated risk of death or amputation compared with autovenous shunting (HR=1.81; 95% CI 1.35-2.21; p=0.03, I²=59%). Endovascular interventions were associated with significantly higher risk of impaired patency of the reconstruction zone with moderate heterogeneity (HR=1.30, 95% CI 1.2-1.56; p=0.005, I²=38%). Similar results were also observed in subgroup analysis of autovenous shunting and infrapopliteal lesions (HR=1.42, 95% CI 1.13-1.67; p=0.009, I²=0%; HR=1.40, 95% CI 1.12-1.80; p=0.007, I²=0%, respectively).

Conclusion: Endovascular interventions yield better 30-day results compared with bypass surgery, including decreased risk of the development of cardiovascular and cerebrovascular complications, infections of postoperative wounds, but leading to an elevated risk of all-cause mortality in the remote postoperative period and impaired patency in the reconstruction zone. We suppose that bypass grafting may be regarded as a first-line strategy of revascularization for patients with a good physical functional state and may have long-term benefits, especially in the presence of a venous bed suitable for shunting.