Angioplasty versus bypass surgery in patients with critical limb ischemia-a meta-analysis

Abstract

Background-Critical limb ischemia (CLI) is one of the most severe peripheral artery diseases. Angioplasty and bypass surgery are two major approaches for the treatment of CLI, however, it remains unclear which treatment has better benefit/risk ratio. In this paper, we performed a meta-analysis on the available clinical trials to compare these two approaches in terms of mortality, amputation-free survival, 5-year leg salvage, and freedom from surgical re-intervention. The results of this article will provide evidence based information for clinical treatment of CLI. Method-Randomized clinical trials comparing results between angioplasty and bypass surgery in CLI were identified by searching Pubmed (2000-2014) and EMBASE (2000-2014) using the search terms "angioplasty" or "bypass", "CLI" and "clinical trials". Primary outcome subjected to meta-analysis was amputation (of trial leg) free survival in 5 years. Secondary outcomes were 30-day mortality; mortality, re-interventions and leg salvage in 1, 3 and 5 years. Results-Seven clinical trials were selected for meta-analysis. No significant difference was found in the primary outcome-amputation free survival, between angioplasty and bypass surgery groups. The amputation free survival in 1, 3 and 5 years were 332/498 (66.7%), 169/346 (48.8%) and 21/60 (35%) in angioplasty group, versus 484/749 (64.6%), 250/494 (50.6%) and 46/132 (34.8%), in bypass group, respectively. The 30 days mortality rate was significantly higher in bypass treatment group [79/1304 (6.1%)] than in angioplasty group [30/918 (3.3%) [95% CI 0.55 [0.36, 0.86], P=0.008). However, there was no statistical significance in 1, 3 and 5 years mortality between these two groups. Two clinical trials showed that there was no difference in leg salvage between angioplasty and bypass surgery groups either. In addition, no difference was observed in re-vasculation between the two groups. Conclusion-Angioplasty is non-inferior to bypass surgery in regarding the amputation free survival, re-vasculation, leg amputation and overall mortality. However, angioplasty is safer, simple, and less invasive and less cost procedure. It should be considered as the first choice for feasible CLI patients.

Keywords: Critical limb ischemia; amputation free survival; angioplasty; bypass; meta analysis.

Figure 1

Flow diagram of study selection.

Figure 2

Forest plots comparing amputation-free survival between angioplasty group and bypass group. A. 1 year amputation-free survival; B. 3 year amputation survival; C. 5 year amputation survival.

Figure 3

Forest plots comparing mortality rate between angioplasty group and bypass group in (A) 30 days; (B) 1 year; (C) 3 years; and (D) 5 years.

Figure 4

Forest plots comparing the leg salvage rate between angioplasty group and bypass group in (A) 1 year; (B) 3 years; and (C) 5 years.

Figure 5

Funnel plot of the studies selected. The plot is for qualitative estimation of publication bias of the studies. No bias was found.