(PC088) Percutaneous thrombectomy has superior outcomes compared to thrombolysis for acute limb ischemia, particularly in patients with severe presentation

Objectives: Catheter directed thrombolysis (CDT) has the potential to reduce mortality in acute limb ischemia (ALI) through a minimally invasive approach, but requires thrombolytic medication and prolonged infusion, limiting use in advanced ischemia. Percutaneous thrombectomy (PT) may obviate the need for thrombolytics and reduce time to reperfusion. However, the impact of the emergence of PT on outcomes of endovascular management of ALI is unclear.

Methods: We included procedures in the VQI (2015-2023) with an urgent/emergent admission and ALI diagnosis who underwent CDT, PT, or both, categorizing patients who underwent both as PT. We excluded patients with COVID, peripheral aneurysms, and those without Rutherford classification or long-term follow-up. Logistic regression evaluated in-hospital amputation, mortality, combined amputation/mortality, and access site complications. Kaplan-Meier estimation and Cox regression evaluated one-year amputation, mortality, combined amputation/mortality, reintervention, and primary patency.

Results: 2,029 procedures (483 CDT, 1,546 PT) were included. Patients who underwent PT were more likely to present with higher Rutherford classification (IIB 44% vs 41%, p=0.04) and distal disease (tibial 41% vs 39%, p=0.05) and less likely to have prior intervention (63% vs 53%, p< 0.001). Less PT patients had conversion to open (2% vs 3%, p=0.02). There were otherwise no significant differences in in-hospital outcomes, although PT patients trended toward decreased amputation (8% vs 10%, p=0.07; aOR=0.76, 95%CI[0.57-1.01], p=0.06). One-year amputation was decreased in PT compared to CDT (9% vs 12%, p=0.04; aHR=0.71, 95%CI[0.52-0.97], p=0.03; Figure). Combined one-year amputation/mortality was non-significantly decreased in PT compared to CDT (23% vs 27%, p=0.07; aHR=0.81, 95%CI[0.66-1.00], p=0.06). One-year mortality, reintervention, and primary patency were no different between groups. Sensitivity analysis of PT alone compared to CDT alone and PT alone compared to PT+CDT showed similar results. Upon subgroup analysis, those with Rutherford IIb ischemia especially benefited from PT with decreased amputation/mortality (IIb aHR=0.65, 95%CI[0.49-0.85], p=0.002; I-IIa aHR=1.06, 95% CI[0.77-1.45], pinteraction=0.02), while those with 1-2a ischemia did not (aHR=1.05, 95%CI[0.77-1.45], p=0.74).

Conclusions: PT with or without the use of concurrent CDT can improve outcomes in patients presenting with ALI, particularly those with Rutherford IIb ischemia. Cost effectiveness of PT devices in lower grade ischemia remains unclear.