Discussion:
Conservative management has been considered a second line management
option for CLI patients after the preferable interventional
revascularization. This was based on the reported high risk of one-year
mortality and amputation associated with untreated CLI [8]. As both
surgical and endovascular interventions are also associated with high
morbidity and mortality, evidence has emerged recently supporting the
suitability of conservative management as a primary option to achieve
AFS in CLI patients even when revascularization is technically feasible
[5].
The current study compared amputation and mortality rates in patients
treated with revascularization and those treated conservatively. The
observed difference in baseline characteristics between the two groups
reflects the current management strategies, where conservative
management is mainly offered to “no-option” patients who have more
advanced disease and medical comorbidities.
While resolution of rest pain and ulcer healing are regarded as the
immediate therapeutic targets of CLI management, prevention of
amputation and prolongation of survival are considered the ultimate
desired outcomes [3]. The results of this study support the argument
that conservative management is comparable to revascularization in terms
of rates of mortality, minor and major amputation, overall AFS and
one-year AFS. Although differences between the two groups were observed
in cumulative OS and AFS, this difference was not observed in the
one-year AFS. Univariate analysis indicates diabetes and chronic kidney
disease as predictors of poor outcome in the conservatively treated
group. These findings support the argument that conservative management
may be an appropriate primary treatment to achieve AFS in selected CLI
patients, as already reported by several other studies [5, 6, 9,
10].
The results of the current study are limited by the observational nature
of the study, therefore further studies are required to inform the most
suitable criteria for identifying patients who can be treated
conservatively even when revascularization is technically achievable.