O-031 - ENDOVASCULAR AND SURGICAL ARTERIALIZATION OF THE FOOT VENOUS SYSTEM FOR NO-OPTION PATIENTS WITH CHRONIC LIMB THREATENING ISCHEMIA: A SYSTEMATIC REVIEW AND METANALYSIS

TOPIC:
Peripheral Occlusive Arterial Disease
AUTHORS:
Ucci A. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Perini P. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Bianchini Massoni C. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Fornasari A. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Cabrini E. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Rossi G. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy) , Ferraresi R. (Diabetic Foot Clinic ~ Paderno Dugnano, Milano (MI) ~ Italy) , Freyrie A. (1- Vascular Surgery, Department of Medicine and Surgery, University of Parma ~ Parma ~ Italy)
Introduction:
Chronic limb threatening ischemia (CLTI) represents a global health problem involving 11% of the 200 million patients affected by peripheral arterial disease (PAD) worldwide[1,2]. Despite the great improvement of surgical and endovascular technique for revascularization, about 20% of CLTI patients are defined as "no-option"[3]. Arterialization of the foot venous system (DVA) have been described as revascularization option for no-option CLTI patients and a growing amount of data have been published in the last years regarding both surgical (sDVA) and percutaneous (pDVA) arterialization. The aim of the study is to review the current literature regarding DVA and to perform a metanalysis regarding procedural and clinical results of this technique.
Methods:
A systematic literature review regarding DVA (databases: Pubmed, Scopus, Cochrane Library and Web of Science) was undertaken until October 2021. After literature screening by two independent authors (AU,PP) to select relevant paper (inclusion criteria: lower limb DVA, human studies, case series with 5 or more patients, full text availability), a systematic review of the selected papers was performed. Furthermore we performed a single-group meta-analysis of proportion using a random-effects model. Paper with no extractable or reported data regarding limb salvage, major amputation or wound healing were excluded. Outcomes considered for the metanalysis were: technical success (defined as successful arterialization of the selected venous system), limb salvage (no need for major limb amputation), global survival and wound healing (defined as complete healing of the wound or marked trend to complete healing in the follow-up according to different papers definition). Outcomes were evaluated for the global population, for sDVA patients and pDVA patients separately. The meta-analysis was performed by OpenMeta (Analyst) and ProMeta 3.0 software (based on ProMeta 2.1, Internovi, Italy) .
Results:
After the literature search process and article screening according to the abovementioned inclusion criteria, 24 papers were included in the systematic review and metanalysis. The selected papers described the outcomes of DVA in 878 CLTI patients treated for 920 limbs. Selected papers regarding only sDVA included 17 articles reporting outcomes of 761 patients treated for 803 limbs. Selected papers regarding pDVA included 7 articles reporting outcomes of 117 patients and limbs. The mean global population age was 65.2 years (95% CI 60.5 - 69.9 - I^2=96.1%) and male sex rate was 75.4% (95% CI 68.9% - 81.9% I^2= 88.2%). Among the global population 16.9% of patients (CI 95% 9.2% - 24.6% I^2= 95.7%) were classified as Rutherford 4 category and 83.1% of patients (CI 95% 75.4% - 90.8% I^2= 95.7%) were classified as Rutherford category 5 or 6. Mean follow-up of the studies was 19.7 months (95% CI 14.8 - 24.6 I^2= 99.2%). Technical success was reported or extractable in 22 papers. Technical success for global population was 98.9% (95% CI 98% - 99.8% I^2= 26.9%). Estimated technical success for sDVA group and pDVA group was 99.1% (95% CI 98.2% - 100% I^2= 34.1%) and 95.8% (95% CI 92.2% - 99.3% I^2= 0%) respectively. Limb salvage was reported or extractable in 24 papers. The limb salvage among the global population was 75.9% (CI 95% 68.6% - 83.3% I^2= 89.9%). Estimated limb salvage rate for sDVA group and pDVA group was 76.5% (95% CI 68% - 85% I^2= 91.6%) and 75.5% (95% CI 67.8% - 83.1% I^2= 0%) respectively. Global survival was reported or extractable in 24 papers. The global survival at the end of follow-up for the entire DVA population was 93.3% (95% CI 90.9% - 95.7% I^2= 78,9%). Estimated global survival for sDVA group and pDVA group was 96% (95% CI 93.9% - 98.1% I^2= 74.5%) and 76.7% (95% CI 64.3% - 89.1% I^2= 68.05%) respectively. Wound healing was reported or extractable in 20 papers. The wound healing rate in the global DVA population was 69.8% (95% CI 59.8% - 79.7% I^2= 93.2%). Estimated wound healing rate for sDVA group and pDVA group was 74.5% (95% CI 63.6% - 85.5% I^2= 93.6%) and 59.5% (95% CI 47.9% - 71% I^2= 37.9%) respectively.
Conclusion:
DVA, both with surgical or endovascular approach, seems a feasible and effective procedure with high rate of technical success. DVA allowed good limb salvage and wound healing rate in no-option CLTI patients, usually burdened by high amputation rate if not treated.
References:
1- M.S Conte et al., "Global vascular guidelines on the management of chronic limb-threatening ischemia", J.VAsc.Surg., vol.69, n.6S, pagg. 3S- 125S.e40, giu.2019, doi: 10.1016/j.jvs.2019.02.016 2- F.G.R. Fowkes et al., "Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis", Lancet Lond.Engl., vol.382, n.9901, pagg. 1329-1340, ott.2013, doi: 10.1016/S0140-6736(13)61249-0. 3- A. Schmidt et al., " Midterm Outcomes of Percutaneous Deep Venous Arterialization With a Dedicated System for Patients With No-Option Chronic Limb-Threatening Ischemia: The ALPS Multicenter Study", J.Endovasc.Ther. Off. J. Int. Soc. Endovasc. Spec., vol.27, n.4, pagg. 658-665, ago.2020, doi: 10.1177/1526602820922179.