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.