Outcomes following Revascularisation for Acute Lower Limb Ischaemia Using Contemporary Endovascular, Hybrid, or Open Surgical Techniques in a Multicentre, Retrospective Cohort: The Acute Lower Limb Ischaemia Vascular Outcomes Evaluation (ALIVE) Registry

ObjectiveTo report peri-operative and midterm outcomes following open surgical, endovascular, and hybrid revascularisation for acute lower limb ischaemia (ALLI) using contemporary techniques and to provide adjusted comparative analyses accounting for key baseline differences.MethodsThis was a multicentre, retrospective study including patients treated for ALLI (January 2016 – November 2024) across 20 international vascular centres. Patients underwent open surgery (55.8%), endovascular treatment (20.2%), or hybrid procedures (24%). Primary outcome was major amputation and or death at the latest follow up. Secondary outcomes included peri-operative death, amputation, acute kidney injury, and re-intervention. Multivariable Cox regression analyses adjusted for age, sex, Rutherford stage, and chronic kidney disease were performed. A Fine–Gray competing risk model accounted for death as a competing event for major amputation.ResultsFrom 19 European centres and one centre in New Zealand, 1 259 patients (55.4% men; mean age 72 ± 14 years; no popliteal aneurysms) were included. At 30 days, the peri-operative mortality rate was 11.2% (open 12.3%, endovascular 3.1%, hybrid 7.4%; p = .042), and major amputation occurred in 9% (open 10.1%, endovascular 8.3%, hybrid 7.2%; p = .41). Median follow up was 36 months (range 8 – 49 months). At 3 years, the estimated mortality rate was 22.9% (standard error [SE] 1.5%) after open, 11.5% (SE 1.9%) after endovascular, and 19.6% (SE 2.2%) after hybrid procedures. Adjusted analyses demonstrated that endovascular treatment was associated with a lower risk of the composite outcome of major amputation and or death compared with open surgery (hazard ratio 0.69, 95% confidence interval [CI] 0.53 – 0.89; p = .005). For major amputation, the Fine–Gray competing risk analysis showed a reduced subdistribution hazard with endovascular treatment (subdistribution hazard ratio 0.71, 95% CI 0.33 – 0.99; p = .006).ConclusionEndovascular ALLI intervention was associated with lower long term amputation risk compared with open surgery, with comparable survival. These findings support endovascular treatment as a safe alternative in patients with ALLI.