Endovascular-first approach is not associated with worse amputation-free survival in appropriately selected patients with critical limb ischemia

Karan Garg, Patrick A. Kaszubski, Rameen Moridzadeh, Caron B. Rockman, Mark A. Adelman, Thomas S. Maldonado, Frank J. Veith, Firas F. Mussa

Research output: Contribution to journalArticlepeer-review

43 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)392-399
Number of pages8
JournalJournal of Vascular Surgery
Issue number2
StatePublished - Feb 2014
Externally publishedYes

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine


Dive into the research topics of 'Endovascular-first approach is not associated with worse amputation-free survival in appropriately selected patients with critical limb ischemia'. Together they form a unique fingerprint.

Cite this