Endovascular versus open surgical approach in patients with acute limb ischemia: A systematic review and meta-analysis

Objective: This meta-analysis compares clinical outcomes and procedural complications of endovascular vs open surgical techniques for the treatment of acute limb ischemia. Methods: PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov were searched from inception to March 1, 2025. Studies comparing endovascular interventions with open surgical techniques for acute limb ischemia were included. Primary outcomes were amputation and mortality rates (early and long term). Secondary outcomes included reintervention, 30-day technical success, hospital stay, and procedural complications. Risk ratios (RRs) and mean differences were calculated using a random-effects model. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. A P value of <.05 was considered statistically significant. Results: Twenty-six studies (4 randomized controlled trials and 22 cohort studies) involving 214,683 patients were included. No significant differences were observed in early amputation rates (RR, 0.93; 95% CI, 0.80-1.09; P = .39; GRADE, very low) or long-term amputation rates. Early mortality (RR, 0.75; 95% CI, 0.56-0.99; P = .05; GRADE, very low) and 6-month mortality (RR, 1.37; 95% CI, 0.70-2.70; P = .45; GRADE, very low) were also similar. However, long-term mortality was significantly lower with the endovascular group at 1, 2, 3, 4, and 5 years. Technical success and 30-day reintervention rates were comparable. Hospital stay was shorter with endovascular treatment (mean difference, −2.43 days; 95% CI, −3.84 to −1.02; GRADE, low). Myocardial infarction, stroke, fasciotomy, and nonintracranial bleeding were similar between groups. However, endovascular therapy was associated with higher intracranial hemorrhage (RR, 1.89; 95% confidence interval, 1.13-3.15; GRADE, low) and lower infection rates (RR, 0.33; 95% CI, 0.15-0.73; GRADE, moderate). Conclusions: Endovascular and open revascularization yielded comparable early outcomes. Endovascular treatment offered modest improvements in long-term survival, shorter hospital stays, and fewer infections, but with an increased risk of intracranial hemorrhage. Given the heterogeneity and limited number of randomized trials, further high-quality evidence is needed.