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Comparative Analysis of Open Versus Percutaneous Thrombectomy in Acute Limb Ischemia: Outcomes of Mortality and Limb Salvage at 30 Days and 1 Year
Mohammad Alsarayreh, Katherine G Welch-Mabon, Chris Agala, Mark A Farber, Katharine McGinigle, Federico E Parodi, Ehsan Benrashid, Luigi Pascarella
University of North Carolina at Chapel Hill, Chapel Hill, NC
BACKGROUND:Acute limb ischemia (ALI) presents a critical challenge with significant morbidity and mortality. The optimal approach for thrombectomy, open versus percutaneous, remains debated, which may impact clinical decision-making and patient outcomes. This study aims to compare these modalities concerning mortality rates and limb salvage outcomes at 30 days and 1 year.
METHODS:Consecutive patients with ALI treated with percutaneous (PT) or open thrombectomy (OT) at a single institution between 2018 and 2023 were identified and reviewed. Patients with iatrogenic or trauma-induced ALI were excluded. Primary outcomes were survival rates and limb loss rates at 30 days and 1 year. Secondary outcomes included rates of thrombolysis, fasciotomy, and stent use. Outcomes were compared between the two groups using Fisher's exact and Chi-square tests for categorical variables, and Wilcoxon Two-Sample test for continuous variables. Limb salvage and survival were assessed by time-to-event methods, including Kaplan-Meier and Cox Proportional Hazards Model, which assessed risk factors associated with survival time using hazard ratios. Logistic regression was used to assess odds of major amputation.
RESULTS:The cohort of 245 patients included 182 limbs (163 patients) treated in the OT group, and 84 limbs (82 patients) in the PT group (89% treated using the Penumbra â system). The cohort was 52.2% male, with a mean age of 64.3±14.6 years. Two hundred eleven (80%) limbs had Rutherford acute classification II (IIa (104) and IIb (107)). A higher prevalence of hypertension(P=0.035) and prior lower extremity interventions(P=0.0005) was observed in the PT group. Acute-on-chronic-ischemia was more prevalent in the PT group(P=0.024). Patients with Rutherford classification I or IIa were more likely to receive PT, while OT was preferred for IIb (P=0.0011). OT cases were more likely to have occlusions in native arteries, whereas PT cases had more frequent occlusions in previous stents and bypasses(P=0.02). Additionally, OT presented with multilevel ischemia involving multiple arterial segments(P=0.023) and a higher prevalence of occlusions in the aortoiliac segment than PT(P=0.0005). PT patients were more likely to receive thrombolysis(P=0.0001) and stents(0.001) while OTs had more fasciotomies(P=0.0001). Reintervention rates were higher at 30-day(P=0.038) and 1-year(P=0.036) for PT(Figure1), and more frequently underwent multiple reinterventions(P=0.044), but amputation rates were not significant at either time point(P=0.52&P=0.56, respectively).
Reintervention type varied significantly, with PT patients more likely to undergo another PT(P=0.016) and OT patients more likely to require a repeat OT(P=0.0005). Time-to-event analysis showed survival rates were higher at 30-days(log-rank, P=0.0004) and 1-year(log-rank,p=0.0003) in the PT-group(Figure2). In total, 68 patients died, of whom 22(32.4%) had major amputation, thus, major amputation was associated with mortality(p=0.0036).
possible.
CONCLUSIONS:Percutaneous thrombectomy demonstrated higher survival and reintervention rates at 30-day and 1-year, with similar limb salvage outcomes. Percutaneous thrombectomy should be considered an effective revascularization approach in patients with acute lower extremity limb ischemia when possible.
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