Gao Jianfeng, Wu Lianglin, Xiang Wenxuan, Li Kehan, Zhou Lei, Zheng Yuehong
Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
Department of Vascular Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
J Endovasc Ther. 2025 May 2:15266028251333701. doi: 10.1177/15266028251333701.
For the treatment of infrapopliteal artery disease (IPAD), endovascular intervention is a main choice, including atherectomy (ATH) and balloon angioplasty. However, the comparative efficacy between both approaches was heterogeneous in prior studies. Lesion length is a critical factor in IPAD anatomy classification. There is no meta-analysis to study the influence of lesion length on the effects of atherectomy for IPAD treatment. This meta-analysis aimed to determine the efficacy of angioplasty with ATH in different ranges of lesion length compared to angioplasty without ATH.
Studies comparing ATH and angioplasty without ATH, which published up to April 2024 were retrieved from Pubmed, Embase, and Web of Science. Endpoints included limb prognosis and vessel complications. Referring to Trans-Atlantic Inter-Society Consensus, 10 cm lesion length was defined as a cutoff value for subgroup analysis. Pooled data were calculated using the Revman 5.4 and Stata 15, presented as odds ratio (OR) with 95% confidence interval (CI). Heterogeneity was calculated using value. Methodological quality was assessed by Cochrane tool and Newcastle-Ottawa Scale. The robustness of findings would be evaluated by sensitivity analysis. Egger's test was performed to detect publication bias.
Eleven studies (8412 patients) were included in this meta-analysis. Significant higher technical success was detected in ATH group (OR=1.99, 95% CI 1.44-2.76, =0%). In a subgroup of mean lesion length <10cm, ATH was associated with lower incidence of dissection (OR=0.19, 95% CI 0.05-0.67, =15%, p=0.01) and bailout stenting (OR=0.18, 95% CI 0.05-0.71, =16%, p=0.01). No significant differences were found between ATH and no ATH cohorts in primary patency (OR=1.65, 95% CI 0.85-3.19), all-cause death (OR=0.75, 95% CI 0.5-1.13), limb salvage (OR=1.03, 95% CI 0.75-1.41), target-lesion revascularization (OR=0.77, 95% CI 0.47-1.27), and embolization (OR=1.19, 95% CI 0.5-2.83).
For IPAD, lesion length is a notable factor affecting the efficacy of ATH. In comparisons with angioplasty without ATH, the use of ATH is contributable in achieving higher technical success. The superiority of ATH may appear in reducing dissection and bailout stenting in treating IPAD with length <10cm. Nevertheless, regardless of lesion length, there seems that ATH cannot effectively improve limb salvage compared to angioplasty alone.Clinical ImpactPrior results of several meta-analyses comparing angioplasty with atherectomy to angioplasty alone were inconsistent in prognosis of infrapopliteal artery disease (IPAD), due to high heterogeneity. Considering the lesion length plays a critical role in IPAD anatomy classification, we performed an updated meta-analysis and subgroup analysis based on average lesion length to furtherly evaluate the efficacy of angioplasty following atherectomy. Our study revealed atherectomy showed advantages in obtaining technical success for IPAD ≥ 10cm and reducing the risks of bailout stenting and dissection for IPAD < 10cm. Atherectomy may prevent target-vessel complications rather than improving late patency and limb salvage effectively.
对于腘下动脉疾病（IPAD）的治疗，血管内介入是主要选择，包括旋切术（ATH）和球囊血管成形术。然而，先前研究中这两种方法的比较疗效存在异质性。病变长度是IPAD解剖分类的关键因素。尚无荟萃分析研究病变长度对IPAD治疗中旋切术效果的影响。本荟萃分析旨在确定与无ATH的血管成形术相比，在不同病变长度范围内进行ATH血管成形术的疗效。
从PubMed、Embase和Web of Science检索截至2024年4月发表的比较ATH与无ATH血管成形术的研究。终点包括肢体预后和血管并发症。参照跨大西洋跨学会共识，将10 cm病变长度定义为亚组分析的临界值。使用Revman 5.4和Stata 15计算合并数据，以比值比（OR）和95%置信区间（CI）表示。使用I²值计算异质性。采用Cochrane工具和纽卡斯尔-渥太华量表评估方法学质量。通过敏感性分析评估研究结果的稳健性。进行Egger检验以检测发表偏倚。
本荟萃分析纳入11项研究（8412例患者）。ATH组检测到显著更高的技术成功率（OR = 1.99，95% CI 1.44 - 2.76，I² = 0%）。在平均病变长度<10 cm的亚组中，ATH与夹层（OR = 0.19，95% CI 0.05 - 0.67，I² = 15%，p = 0.01）和补救性支架置入（OR = 0.18，95% CI 0.05 - 0.71，I² = 16%，p = 0.01）发生率较低相关。ATH组与无ATH组在原发性通畅率（OR = 1.65，95% CI 0.85 - 3.19）、全因死亡（OR = 0.75，95% CI 0.5 - 1.13）、肢体挽救（OR = 1.03，95% CI 0.75 - 1.41）、靶病变血运重建（OR = 0.77，95% CI 0.47 - 1.27）和栓塞（OR = 1.19，95% CI 0.5 - 2.83）方面未发现显著差异。
对于IPAD，病变长度是影响ATH疗效的一个显著因素。与无ATH的血管成形术相比，使用ATH有助于实现更高的技术成功率。ATH的优势可能体现在治疗长度<10 cm的IPAD时减少夹层和补救性支架置入。然而，无论病变长度如何，与单独的血管成形术相比，ATH似乎不能有效改善肢体挽救。临床影响先前几项比较血管成形术与旋切术和单独血管成形术的荟萃分析结果在腘下动脉疾病（IPAD）的预后方面不一致，原因是异质性高。考虑到病变长度在IPAD解剖分类中起关键作用，我们基于平均病变长度进行了更新的荟萃分析和亚组分析，以进一步评估旋切术后血管成形术的疗效。我们的研究表明，旋切术在IPAD≥10 cm时获得技术成功以及在IPAD<10 cm时降低补救性支架置入和夹层风险方面具有优势。旋切术可能预防靶血管并发症，而不是有效改善远期通畅率和肢体挽救。
