Systematic Review and Meta-analysis of Direct Versus Indirect Angiosomal Revascularisation of Infrapopliteal Arteries

ObjectiveThe aim of this systematic review was to evaluate outcomes of direct revascularisation (DR) versus indirect revascularisation (IR) of infrapopliteal arteries to the affected angiosome for critical limb ischaemia. Both open and endovascular techniques were included.MethodsA systematic review of key electronic journal databases was undertaken from inception to 22 March 2014. Studies comparing DR versus IR in patients with localised tissue loss were included. Meta-analysis was performed for wound healing, limb salvage, mortality, and re-intervention rates, with numerous sensitivity analyses. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.ResultsFifteen cohort studies reporting on 1,868 individual limbs were included (endovascular revascularisation, 1,284 limbs; surgical revascularisation, 508 limbs; both methods, 76 limbs). GRADE quality of evidence was low or very low for all outcomes. DR resulted in improved wound healing rates compared with IR (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.29-0.54) and improved limb salvage rates (OR 0.24, 95% CI 0.13-0.45), although this latter effect was lost on high-quality study sensitivity analysis. Wound healing and limb salvage was improved for both open and endovascular intervention. There was no effect on mortality (OR 0.77, 95% CI 0.50-1.19) or reintervention rates (OR: 0.44, 95% CI 0.10-1.88).ConclusionDR of the tibial vessels appears to result in improved wound healing and limb salvage rates compared with IR, with no effect on mortality or reintervention rates. However, the quality of evidence on which these conclusions are based on is low.