Three-Year Outcomes of Surgical Versus Endovascular Revascularization for Critical Limb Ischemia: The SPINACH Study (Surgical Reconstruction Versus Peripheral Intervention in Patients With Critical Limb Ischemia)

Circ Cardiovasc Interv. 2017 Dec;10(12):e005531. doi: 10.1161/CIRCINTERVENTIONS.117.005531.


Background: The aim of this study was to compare clinical outcomes between surgical reconstruction and endovascular therapy (EVT) for critical limb ischemia (CLI) in today's real-world settings.

Methods and results: This multicenter, prospective, observational study registered and followed 548 Japanese CLI patients. The registration was in advance of revascularization; 197 patients were scheduled to receive surgical reconstruction, and the remaining 351 were scheduled to receive EVT. The primary end point was 3-year amputation-free survival, compared between the 2 treatments in an intention-to-treat manner, using propensity score matching. Interaction analysis was additionally performed to explore which subgroups had better outcomes with surgical reconstruction or EVT. After propensity score matching, the 3-year amputation-free survival was not significantly different between the 2 groups (52% [95% confidence interval, 43%-60%] and 52% [95% confidence interval, 44-60%]; P=0.26). Subsequent interaction analysis identified (1) Wound, Ischemia, and foot Infection (WIfI) classification W-3, (2) fI-2/3, (3) history of ipsilateral minor amputation, (4) history of revascularization after CLI onset, and (5) bilateral CLI as the factors more favorable for surgical reconstruction, whereas (1) diabetes mellitus, (2) renal failure, (3) anemia, (4) history of nonadherence to cardiovascular risk management, and (5) contralateral major amputation were as those less favorable for surgical reconstruction.

Conclusions: The 3-year amputation-free survival was not different between surgical reconstruction and EVT in the overall CLI population. The subsequent interaction analysis suggested that there would be a subgroup more suited for surgical reconstruction and another benefiting more from EVT.

Clinical trial registration: URL: Unique identifier: UMIN000007050.

Keywords: amputation-free survival; critical limb ischemia; endovascular therapy; propensity score; surgical reconstruction.

Publication types

  • Comparative Study
  • Multicenter Study
  • Observational Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Amputation
  • Chi-Square Distribution
  • Comorbidity
  • Critical Illness
  • Disease-Free Survival
  • Endovascular Procedures* / adverse effects
  • Female
  • Humans
  • Intention to Treat Analysis
  • Ischemia / physiopathology
  • Ischemia / surgery
  • Ischemia / therapy*
  • Kaplan-Meier Estimate
  • Limb Salvage
  • Logistic Models
  • Male
  • Middle Aged
  • Peripheral Arterial Disease / physiopathology
  • Peripheral Arterial Disease / surgery
  • Peripheral Arterial Disease / therapy*
  • Propensity Score
  • Proportional Hazards Models
  • Prospective Studies
  • Regional Blood Flow
  • Registries
  • Risk Factors
  • Time Factors
  • Treatment Outcome
  • Vascular Surgical Procedures* / adverse effects