Network Meta-analysis of Randomised Controlled Trials Comparing the Outcomes of Different Endovascular Revascularisation Treatments for Infra-inguinal Peripheral Arterial Disease Causing Chronic Limb Threatening Ischaemia

Shivshankar Thanigaimani; David Sun; Usama Ahmad; Naomi Anning; Kevin Tian; Jonathan Golledge

doi:10.1016/j.ejvs.2024.05.014

Network Meta-analysis of Randomised Controlled Trials Comparing the Outcomes of Different Endovascular Revascularisation Treatments for Infra-inguinal Peripheral Arterial Disease Causing Chronic Limb Threatening Ischaemia

Eur J Vasc Endovasc Surg. 2024 May 14:S1078-5884(24)00392-7. doi: 10.1016/j.ejvs.2024.05.014. Online ahead of print.

Authors

Shivshankar Thanigaimani¹, David Sun², Usama Ahmad³, Naomi Anning⁴, Kevin Tian², Jonathan Golledge⁵

Affiliations

¹ Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia.
² Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia.
³ Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.
⁴ Sunshine Coast University Hospital, Birtinya, Queensland, Australia.
⁵ Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia. Electronic address: Jonathan.Golledge@jcu.edu.au.

PMID: 38754723
DOI: 10.1016/j.ejvs.2024.05.014

Abstract

Objective: The aim of this study was to compare the efficacy of different endovascular revascularisation procedures for treating chronic limb threatening ischaemia (CLTI) using network meta-analysis (NMA).

Data sources: The databases PubMed and Cochrane Central Register for Controlled Trials were searched on 14 March 2023.

Review methods: A NMA of randomised controlled trials (RCTs) reporting the efficacy of different endovascular revascularisation techniques for treating CLTI was performed according to PRISMA guidelines. The primary and secondary outcomes were major amputation and mortality, respectively. Random effects models were developed and the results were presented using surface under the cumulative ranking curve plots and forest plots. A p value of ≤ .050 was considered statistically significant. The Cochrane collaborative tool was used to assess risk of bias.

Results: A total of 2 655 participants of whom 94.8% had CLTI were included. Eleven trials compared plain balloon angioplasty (PBA) vs. drug coated balloon (DCB) angioplasty (n = 1 771), five trials compared bare metal stent (BMS) vs. drug coated stent (DCS) (n = 466), three trials compared atherectomy vs. DCB (n = 194), two trials compared PBA vs. BMS (n = 70), one trial compared PBA vs. atherectomy (n = 50), and one trial compared BMS vs. DCB (n = 104). None of the revascularisation strategies significantly reduced the risk of major amputation or mortality compared with PBA. Using the network estimates, GRADE certainty of evidence for improvement in major amputation outcomes for DCB was moderate, for atherectomy and BMS was low, and for DCS was very low compared with PBA. Risk of bias was low in 16 trials, some concerns in six trials, and high in 1 trial, respectively.

Conclusion: There is no current evidence from RCTs to reliably conclude that BMS, DCB, DCS, or atherectomy are superior to PBA in preventing major amputation and mortality in patients with CLTI. Larger comparative RCTs are needed to identify the best endovascular revascularisation strategy.

Keywords: Chronic limb threatening ischaemia; Endovascular revascularisation; Infra-inguinal; Network meta-analysis; Peripheral arterial disease.

Publication types

Review