Revascularization, whether endovascular or surgical, is reserved for patients with intermittent claudication symptoms refractory to medical therapy, critical limb ischemia and acute limb ischemia. The choice between endovascular and surgical intervention is done on case-to-case basis; however, endovascular intervention is usually chosen first and surgery is done when the non surgical intervention fails. In addition, the anatomic characteristics of the PAD lesions guides the management plan. Amputation might be required in severe cases of critical limb ischemia.
Surgery
Indications for Revascularization
Intermittent Claudication
Revascularization is indicated in selected cases of patients with intermittent claudication, which includes the following:
Significant functional impairment that limits the daily activity and quality of life of the patient.
Absence of other diseases, like congestive heart failure or angina, that may limit exercise after a successful improvement of the claudication.
A favorable lower extremity PAD anatomy that carries low complication risks and high chance of success with revascularization.
Critical Limb Ischemia
All patients with symptoms of critical limb ischemia (ulcers, gangrene or rest pain) must be evaluated for the risks, benefits and optimal time for revascularization.
Patients suffering from critical limb ischemia will undergo amputation in 6 months in the absence of revascularization.
Acute Limb Ischemia
All patients with acute limb ischemia must have an urgent anatomic evaluation of the PAD lesion and a prompt revascularization.[1]
Endovascular vs Surgical Intervention
Intermittent Claudication
Endovascular interventions are usually the initial revascularization strategies for patients with claudication.
Surgical intervention is considered for individuals in whom arterial anatomy is not favorable for endovascular procedures.
Morphological anatomic features are used to classify the PAD lesions according to the TASC classification and guide the choice between endovascular and surgical revascularization.
Critical Limb Ischemia
The choice between endovascular and surgical intervention is challenging in patients with critical limb ischemia.
Most importantly, critical limb ischemia must be differentiated from acute limb ischemia in order to guide the treatment.
The decision on the type of intervention is done case to case by taking into consideration the age of the arterial anatomy as well as the presence of any comorbidities.
Morphological anatomic features are used to classify the PAD lesions according to the TASC classification and guide the choice between endovascular and surgical revascularization.
In general, endovascular intervention is the first choice and surgery is attempted when endovascular intervention fails.
Life threatening ischemia, infected lesions, gangrene may require amputation with or without need for revascularization.
Acute Limb Ischemia
When the limb is viable or salvageable, revascularization (whether endovascular or surgical) is urgently done.
The decision on the type of intervention is done case to case by taking into consideration the age of the arterial anatomy as well as the presence of any comorbidities.
Morphological anatomic features are used to classify the PAD lesions according to the TASC classification and guide the choice between endovascular and surgical revascularization.
In general, endovascular intervention is the first choice and surgery is attempted when endovascular interventions fails.
When the limb is not viable, amputation is done[1].
The Choice of the Revascularization Intervention Based on TASC Classification
For detailed information regarding the TASC classification, click here.
Iliac Lesions
Endovascular revascularization is the intervention of choice in patients with TASC type A iliac lesions.
TASC type A iliac lesions is defined as a single stenosis less than 3 cm of the common iliac artery or external iliac artery (unilateral/bilateral).
Surgical revascularization is the intervention of choice in patients with TASC type D iliac lesions.
TASC type D iliac lesions is defined as either one of the following:
Diffuse, multiple unilateral stenoses involving the common iliac artery, external iliac artery, and common femoral artery (usually more than 10 cm long)
Unilateral occlusion involving both the common iliac artery and external iliac artery
Bilateral external iliac artery occlusions
Diffuse disease involving the aorta and both iliac arteries
Iliac stenoses in a patient with an abdominal aortic aneurysm or other lesion requiring aortic or iliac surgery.
As for TASC type B iliac lesions and TASC type C iliac lesions, the choice between endovascular and surgical revascularization requires the evaluation of the percentage of artery stenosis.
Femoral Lesions
Endovascular revascularization is the intervention of choice in patients with TASC type A femoropopliteal lesions.
TASC type A femoropopliteal lesions is defined as a single stenosis less than 3 cm of the superficial femoral artery or popliteal artery.
Surgical revascularization is the intervention of choice in patients with TASC type D femoropopliteal lesions.
TASC type D femoropopliteal lesions is defined as complete common femoral artery or superficial femoral artery occlusions or complete popliteal and proximal trifurcation occlusions.
As for TASC type B femoropopliteal lesions and TASC type C femoropopliteal lesions, the choice between endovascular and surgical revascularization is not definite.[1]
Patients suffering from combined inflow and outflow diseases should have correction of the inflow problems first.
A correction of the inflow problems provides a significant improvement in inflow to an extent that it decreases the severity of claudication which can be controlled by conservative management.
A correction of the inflow problems decreases the risk of distal graft thrombosis when distal revacularization is needed.
Vascular Surgical Procedures for Inflow Improvement
Aortobifemoral bypass
Aortoiliac or aortofemoral bypass
Iliac endarterectomy
Femorofemoral bypass
Axillofemoral bypass
Axillofemoral-femoral bypass
Vascular Surgical Procedures for Outflow Improvement
2011 and 2005 ACCF/AHA Guidelines for the Management of Patients With Peripheral Artery Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic) (DO NOT EDIT)[1][2]
Critical Limb Ischemia: Endovascular and Open Surgical Treatment for Limb Salvage (DO NOT EDIT)[1][2]
"1. For individuals with combined inflow and outflow disease with critical limb ischemia, inflow lesions should be addressed first. (Level of Evidence: C)"
"2. For individuals with combined inflow and outflow disease in whom symptoms of critical limb ischemia or infection persist after inflow revascularization, an outflow revascularization procedure should be performed.[3](Level of Evidence: B)"
"1. For patients with limb-threatening lower extremity ischemia and an estimated life expectancy of 2 years or less or in patients in whom an autogenous vein conduit is not available, balloon angioplasty is reasonable to perform when possible as the initial procedure to improve distal blood flow.[4](Level of Evidence: B)"
"2. For patients with limb-threatening ischemia and an estimated life expectancy of more than 2 years, bypass surgery, when possible and when an autogenous vein conduit is available, is reasonable to perform as the initial treatment to improve distal blood flow.[4](Level of Evidence: B)"
"1. When surgery is to be undertaken, aortobifemoral bypass is recommended for patients with symptomatic, hemodynamically significant, aorto-bi-iliac disease requiring intervention. (Level of Evidence: A)"
"2. Iliac endarterectomy, patch angioplasty, or aortoiliac or iliofemoral bypass in the setting of acceptable aortic inflow should be used for the treatment of unilateral disease or in conjunction with femoral-femoral bypass for the treatment of a patient with bilateral iliac artery occlusive disease if the patient is not a suitable candidate for aortobifemoral bypass grafting. (Level of Evidence: B)"
"3. Axillofemoral-femoral bypass is indicated for the treatment of patients with CLI who have extensive aortoiliac disease and are not candidates for other types of intervention. (Level of Evidence: B)"
Outflow Procedures:Infrainguinal Disease in CLI Patients (DO NOT EDIT)[1]
"3. The most distal artery with continuous flow from above and without a stenosis greater than 20% should be used as the point of origin for a distal bypass.(Level of Evidence: B)"
"5. Femoral-tibial artery bypasses should be constructed with autogenous vein, including the ipsilateral greater saphenous vein, or if unavailable, other sources of vein from the leg or arm. (Level of Evidence: B)"
"6. Composite sequential femoropopliteal-tibial bypass and bypass to an isolated popliteal arterial segment that has collateral outflow to the foot are both acceptable methods of revascularization and should be considered when no other form of bypass with adequate autogenous conduit is possible. (Level of Evidence: B)"
"7. If no autogenous vein is available, a prosthetic femoral-tibial bypass, and possibly an adjunctive procedure, such as arteriovenous fistula or vein interposition or cuff, should be used when amputation is imminent. (Level of Evidence: B)"
"2. Patients who have undergone placement of aortobifemoral bypass grafts should be followed up with periodic evaluations that record any return or progression of ischemic symptoms, the presence of femoral pulses, and ABIs. (Level of Evidence: B). "
"4. Patients who have undergone placement of a lower extremity bypass with autogenous vein should undergo for at least 2 years periodic examinations that record any return or progression of ischemic symptoms; a physical examination, with concentration on pulse examination of the proximal, graft, and outflow vessels; and duplex imaging of the entire length of the graft, with measurement of peak systolic velocities and calculation of velocity ratios across all lesions. (Level of Evidence: A). "
"5. Patients who have undergone placement of a synthetic lower extremity bypass graft should undergo periodic examinations that record any return of ischemic symptoms; a pulse examination of the proximal, graft, and outflow vessels; and assessment of ABIs at rest and after exercise for at least 2 years after implantation. (Level of Evidence: A). "
Prior Limb Arterial Revascularization in PAD Patients (DO NOT EDIT)[1]
"1. Long-term patency of infrainguinal bypass grafts should be evaluated in a surveillance program, which should include an interval vascular history, resting ABIs, physical examination, and a duplex ultrasound at regular intervals if a venous conduit has been used.(Level of Evidence: B)"
"1. Long-term patency of infrainguinal bypass grafts may be considered for evaluation in a surveillance program, which may include conducting exercise ABIs and other arterial imaging studies at regular intervals. (Level of Evidence: B)"
"2. Long-term patency of endovascular sites may be evaluated in a surveillance program, which may include conducting exercise ABIs and other arterial imaging studies at regular intervals. (Level of Evidence: B)"
Endovascular Treatment for Claudication (DO NOT EDIT)[1]
"1.Endovascular procedures are indicated for individuals with a vocational or lifestyle-limiting disability due to intermittent claudication when clinical features suggest a reasonable likelihood of symptomatic improvement with endovascular intervention and (a) there has been an inadequate response to exercise or pharmacological therapy and/or (b) there is a very favorable risk-benefit ratio (e.g., focal aortoiliac occlusive disease). (Level of Evidence: A)"
"2. Endovascular intervention is recommended as the preferred revascularization technique for TASC type A (see Tables 20 and 21 and Figure 8) iliac and femoropopliteal arterial lesions. (Level of Evidence: B)"
"4. Provisional stent placement is indicated for use in the iliac arteries as salvage therapy for a suboptimal or failed result from balloon dilation (e.g., persistent translesional gradient, residual diameter stenosis greater than 50%, or flow-limiting dissection). (Level of Evidence: B)"
"1. The effectiveness of stents, atherectomy, cutting balloons, thermal devices, and lasers for the treatment of femoral-popliteal arterial lesions (except to salvage a suboptimal result from balloon dilation) is not well established.(Level of Evidence: A)"
"2. The effectiveness of uncoated/uncovered stents, atherectomy, cutting balloons, thermal devices, and lasers for the treatment of infrapopliteal lesions (except to salvage a suboptimal result from balloon dilation) is not well established. (Level of Evidence: C)"
"1.Surgical interventions are indicated for individuals with claudication symptoms who have a significant functional disability that is vocational or lifestyle limiting, who are unresponsive to exercise or pharmacotherapy, and who have a reasonable likelihood of symptomatic improvement. (Level of Evidence: B)"
"1. Because the presence of more aggressive atherosclerotic occlusive disease is associated with less durable results in patients younger than 50 years of age, the effectiveness of surgical intervention in this population for intermittent claudication is unclear. (Level of Evidence: B)"
Inflow Procedures: Aortoiliac Occlusive Disease (DO NOT EDIT)[1]
"2. Iliac endarterectomy and aortoiliac or iliofemoral bypass in the setting of acceptable aortic inflow should be used for the surgical treatment of unilateral disease or in conjunction with femoral-femoral bypass for the treatment of a patient with bilateral iliac artery occlusive disease if the patient is not a suitable candidate for aortobifemoral bypass grafting. (Level of Evidence: B)"
"1. Axillofemoral-femoral bypass should not be used for the surgical treatment of patients with intermittent claudication except in very limited settings (see Class IIb recommendation above). (Level of Evidence: B)"
"1. Axillofemoral-femoral bypass may be considered for the surgical treatment of patients with intermittent claudication in very limited settings, such as chronic infrarenal aortic occlusion associated with symptoms of severe claudication in patients who are not candidates for aortobifemoral bypass. (Level of Evidence: B)"
Outflow Procedures: Infrainguinal Disease (DO NOT EDIT)[1]
"1. The use of synthetic grafts to the popliteal artery below the knee is reasonable only when no autogenous vein from ipsilateral or contralateral leg or arms is available. (Level of Evidence: A)"
"1. Femoral-tibial artery bypasses constructed with autogenous vein may be considered for the treatment of claudication in rare instances for certain patients (see text). (Level of Evidence: B)"
"2. Because their use is associated with reduced patency rates, the effectiveness of the use of synthetic grafts to the popliteal artery above the knee is not well-established. (Level of Evidence: B)"
Follow-up after Vascular Surgical Procedures (DO NOT EDIT)[1]
"1. Patients who have undergone placement of aortobifemoral bypass grafts should be followed up with periodic evaluations that record any return or progression of claudication symptoms, the presence of femoral pulses, and ABIs at rest and after exercise. (Level of Evidence: C)"
"2. Patients who have undergone placement of a lower extremity bypass with autogenous vein should undergo periodic evaluations for at least 2 years that record any claudication symptoms; a physical examination and pulse examination of the proximal, graft, and outformed flow vessels; and duplex imaging of the entire length of the graft, with measurement of peak systolic velocities and calculation of velocity ratios across all lesions. (Level of Evidence: C)"
"3. Patients who have undergone placement of a synthetic lower extremity bypass graft should, for at least 2 years after implantation, undergo periodic evaluations that record any return or progression of claudication symptoms; a pulse examination of the proximal, graft, and outflow vessels; and assessment of ABIs at rest and after exercise. (Level of Evidence: C)"