When should Open Surgery be the Initial Option for Critical Limb Ischaemia?

ObjectivesThe treatment paradigm for patients with critical limb ischaemia (CLI) has changed over the past decade with an increase in endovascular interventions. Accompanying this shift has been a fundamental question as to whether open surgery or endovascular therapy represents the optimal treatment for CLI.DesignReview.MethodsA review of open versus endovascular surgery was performed. The supporting arguments by respective clinicians of both an ‘open first’ and an ‘endo first’ approach are summarised, followed by the available evidence in the literature for each. A summary of an informal survey of endovascular surgeons regarding five indications for an ‘open first’ approach to CLI are reviewed. Present and future clinical tools and research for providing a more objective decision for intervention in CLI are then summarised.ResultsSupporters of either an ‘open first’ or ‘endo first’ approach make claims which are not entirely supported by the current level 1 evidence. Five conditions which endovascular surgeons agree that patients with CLI should be treated primarily by open revascularisation include common femoral artery pathology; arterial occlusions caused by extrinsic compression pathologies; extensive foot gangrene/sepsis; young patients and those requiring dependent-free soft tissue reconstructions where durability is paramount; and infrageniculate popliteal and proximal tibial occlusion with single, distal tibial target vessel. Clinical scoring systems and mathematical modelling of lower extremity disease assist in making a prospective intervention decision.ConclusionThe treatment of CLI has changed and continued clinical and research work is focussed on which intervention is more effective. While more attempts at endovascular treatment are made, there remain specific indications for open surgical treatment of CLI. As more work is done towards determining optimal intervention choices on a patient-specific basis, clearer indications for either intervention will emerge.