A Systematic Review and Meta-Analysis of Reported Success and Complication Outcomes the Management of Acute Upper Limb Ischemia.

BACKGROUND

Acute upper limb ischemia (AULI) is a surgical emergency whereby the upper limb blood supply is threatened, leading to a risk of limb loss, functional disability, or life-threatening complications. A variety of strategies for management exists and include, anticoagulation (termed medical management), open surgery, and endovascular techniques. There are no clear guidelines on how AULI should be managed safely. This review aimed to explore the current strategies of AULI and their associated outcomes.

METHODS

A systematic review was performed in accordance with PRISMA guidelines and registered prospectively in PROSPERO (CRD420251005180). MEDLINE, EMBASE, CINAHL, and CENTRAL were searched from inception to September 2025. Observational studies reporting outcomes following surgical, endovascular or medical management of AULI were included. Risk of bias was assessed using ROBINS-I and certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Random-effects proportional meta-analysis was performed using Stata.

RESULTS

Twenty-seven studies (3,162 patients) were included, with no randomized controlled trials identified. Reported overall success rates were 90.1% (95% confidence interval [CI]: 84.5-94.7%) for surgical management, 71.8% (95% CI: 41.1-94.9%) for endovascular management and 79.4% (95% CI: 52.6-97.8%) for medical management. Substantial heterogeneity was observed across all treatment groups (I2>87%). Reported complication and reintervention rates varied widely across studies. All 27 studies were assessed as having a high risk of bias, mainly due to lack of adjustment for confounding factors and incomplete baseline severity reporting. Certainty of evidence was low to very low.

CONCLUSION

The current evidence describing outcomes following AULI management is limited, heterogeneous and predominantly derived from retrospective observational studies that lacked standardized outcome definitions and long-term functional follow-up data. Due to confounding by indication and lack of direct comparisons, reliable conclusions regarding relative effectiveness between treatment strategies cannot be made. Prospective multicenter studies and randomized trials are required.