Comparative midterm outcomes of contemporary revascularization strategies for acute lower limb ischemia: a retrospective cohort study

Abstract

Acute lower limb ischaemia (ALLI) is a vascular emergency associated with high morbidity and mortality. Contemporary revascularization strategies include open surgery,endovascular intervention,and hybrid approaches,yet comparative midterm outcomes remain incompletely defined. We conducted a single - center retrospective cohort study of 842 consecutive patients with ALLI treated at Xinxiang City Central Hospital between January 2019 and December 2023,with follow - up complete through May 2026.Patients underwent open surgery( n  = 452),endovascular intervention( n  = 198),or hybrid procedures ( n  = 192). Baseline characteristics, peri-operative outcomes, and long - term events were collected. The pre - specified primary outcome was the composite of major amputation and/or all-cause mortality at 3 years. Secondary outcomes included individual components, peri-operative mortality, acute kidney injury, and re-intervention. Multivariable Cox regression and Fine-Gray competing risk models were applied, together with propensity score inverse probability of treatment weighting (IPTW) as sensitivity analyses. The mean age was 74 ± 13, 70 ± 12,and 71 ± 13 years in the open, endovascular, and hybrid groups, respectively. Endovascular treatment was associated with lower peri - operative mortality (adjusted OR 0.32,95% CI 0.15–0.68, p  = 0.003) and reduced acute kidney injury (OR 0.48,95% CI 0.25–0.92, p  = 0.027).Over a median follow - up of 34 months (IQR 28–41),cumulative 3 - year major amputation rates were 11.6%, 21.9%, and 13.5%,and all - cause mortality 24.1%,12.8%,and 20.3% in the open, endovascular, and hybrid groups,respectively.In adjusted competing-risk regression, endovascular treatment was associated with a lower subdistribution hazard of major amputation (sHR 0.69, 95% CI 0.49–0.97, p  = 0.034); however, this association was model-dependent and contrasted with the higher crude amputation incidence observed in the endovascular group. Endovascular treatment was also associated with a lower risk of the composite endpoint of major amputation and/or all-cause mortality (HR 0.71, 95% CI 0.56–0.90, p  = 0.006), whereas hybrid approaches did not differ significantly from open surgery. Endovascular revascularization for ALLI offers improved peri - operative safety and favorable midterm composite outcomes compared with open surgery in this observational cohort. Hybrid strategies demonstrate intermediate results. These findings support individualized treatment selection, but definitive causal inferences are limited by the non - randomized design and potential residual confounding.