Comparative Safety and Effectiveness of Endovascular Versus Surgical Treatment for Acute Limb Ischemia: A Systematic Review and Meta-Analysis

Objective: Acute limb ischemia (ALI) is a limb- and life-threatening vascular emergency that necessitates prompt revascularization. While both surgical and endovascular interventions are established treatment modalities, contemporary comparative data remain limited. The study aims to evaluate and compare outcomes between these revascularization strategies. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review and meta-analysis were performed. Three databases were searched through January 2026. All studies comparing endovascular versus surgical treatment for ALI were identified. Outcomes of interest included periprocedural and mid-term mortality, major amputation, and reintervention rates. Mid-term outcomes were defined as events occurring at any point during the reported follow-up period. Risk ratios (RRs) or hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted and analyzed using a random-effects model. Results: Twenty-four studies (5 randomized controlled trials, 2 prospective, and 17 retrospective observational studies) comprising 382 465 patients (endovascular: 172 308; surgical: 210 157) were analyzed. In these studies, there was no difference in periprocedural mortality between endovascular and surgical treatment (RR 0.84, 95% CI 0.62-1.14). Endovascular treatment was associated with lower mid-term mortality compared with surgical revascularization (HR 0.84, 95% CI 0.76-0.94). Major amputation showed a similar trend, with comparable periprocedural risk (RR 0.93, 95% CI 0.51-1.71) and reduced mid-term risk with endovascular therapy (HR 0.84, 95% CI 0.77-0.91). Periprocedural reintervention rates were significantly higher in the endovascular group (RR 1.94, 95% CI 1.80-2.08), while mid-term reintervention rates were comparable (HR 1.79, 95% CI 0.79-4.06). Conclusion: In this contemporary meta-analysis of patients treated for ALI, endovascular revascularization was associated with lower mid-term mortality and major amputation rates, whereas surgical intervention was linked to a lower risk of periprocedural reintervention. These findings underscore the importance of a multidisciplinary approach involving a dedicated vascular team to ensure optimal, patient-tailored management. Clinical Trial Registration: Prospective Register of Systematic Reviews, ID=1042195. Clinical Impact Acute limb ischemia (ALI) carries high morbidity and mortality, yet comparative data on endovascular versus surgical revascularization are limited. In this meta-analysis of 24 studies including 382 465 patients, periprocedural mortality was similar between approaches, but endovascular therapy reduced mid-term mortality and major amputation risk, despite higher periprocedural reintervention rates. These findings suggest that endovascular-first strategies may be a safe and effective alternative to surgical revascularization. Optimal care requires a multidisciplinary vascular team to tailor interventions, balancing immediate procedural risks with long-term outcomes for each patient.