Rotational Percutaneous Mechanical Thrombectomy for Acute and Subacute Limb Ischaemia: A Systematic Review and Proportional Meta-Analysis

Objective Rotational percutaneous mechanical thrombectomy with adjunctive angioplasty, stenting or limited thrombolysis (rPMT+) has become commonplace in the treatment of acute and subacute limb ischaemia. This systematic review and proportional meta-analysis synthesises the available evidence on its safety and efficacy. Data Sources MEDLINE, Embase and the Cochrane Library. ≥ Review Methods We searched for studies (≥10 patients) published since 1 January 2012 (PROSPERO protocol CRD420251015846). Risk of bias was assessed using RoBANS 2. Proportional meta-analysis maximised representative sample sizes by incorporating both single-arm and comparative studies. GRADE evidence profiles were developed for each outcome of interest. Results Twenty-four studies – seven comparative and 17 single arm – containing 2,954 procedures (2,697 rPMT+, 257 controls) met eligibility criteria. There were no randomised controlled trials. The pooled technical success (TS) rate for rPMT+ was 98% (95% CI: 97-100%, p <0.001). Amputation-free survival (AFS) was 96% (95% CI: 93-98%, p <0.001). Twelve-month primary patency (PP) was 68% (95% CI: 55-79%, p <0.001). The pooled rate of freedom from clinically-driven target lesion revascularisation (fCDTLR) was 85% (95% CI: 80-90%, p <0.001). No significant differences existed between acute, subacute and mixed subgroups. Procedure-related mortality was 0.5% (11 deaths in 2,086 procedures from 17 studies) with most deaths occurring after adjunctive catheter-directed thrombolysis. Major adverse events occurred in 4% of procedures (95% CI: 1-8%, p <0.001) and distal embolization in 8% (95% CI: 5-11%, p <0.001). rPMT+ reduced length of stay by 1.7 days versus alternatives (95% CI: 3.3-0.1 days, p <0.05). All outcomes demonstrated heterogeneity. GRADE assessment rated evidence certainty as low to very low. Conclusion rPMT+ delivers consistently high TS and AFS rates, promising 12-month fCDTLR, acceptable PP, low procedural risk and shorter hospital stays than comparators. The consistency of favourable outcomes supports its use as a safe and effective treatment in appropriately selected ALI and SLI patients. WHAT THIS PAPER ADDS This systematic review and proportional meta-analysis synthesises 24 single-arm and comparative non randomised studies encompassing nearly 3,000 procedures to provide a comprehensive assessment of the safety and efficacy of rotational percutaneous mechanical thrombectomy in patients with acute and subacute lower limb ischaemia. It demonstrates that, when used for initial revascularisation prior to adjunctive angioplasty, stenting or limited thrombolysis, this endovascular approach delivers consistently high rates of technical success and amputation-free survival with notably high rates of freedom from clinically-driven target lesion revascularisation, acceptable primary patency, low procedural risk and significantly shorter hospital stays.