The battle of endovascular therapy versus open surgical therapy for the treatment of pathologic processes in all vascular beds continues, but we are beginning to see the end. We have moved from the philosophy that only open revascularization provides effective and durable results to the growing consensus that more minimally invasive endovascular procedures can be performed safely, with reduced risk and with a level of effective clinical improvement and durability that is acceptable. Continued success requires close follow-up and repeat intervention judiciously applied when clinically warranted. In our practice and many others, open surgical procedures are reserved for failures of endovascular therapy.

Optimal medical management remains the foundation of treatment in all patients with vascular disease (Table 39.3). Lifestyle modifications with risk factor reduction include exercise, healthy diet, exercise, and smoking cessation. Optimal medical therapy involves strict blood glucose and hypertension control with antiplatelet and statin therapies. Patients with IC are often adequately treated with lifestyle medication and optimal medical therapy since these treatments lead to slow progression of disease with low risk of amputation or limb loss. However, in patients with lifestyle-limiting claudication, rest

pain, or tissue loss there may be compelling reasons to intervene. For the claudicants it is to enhance quality of life while allowing for more effective exercise activity; for those with critical limb ischemia intervention is imperative given their higher risk of limb loss or amputation. Open surgical lower extremity bypass in infrainguinal arterial disease has resulted in excellent outcomes for many years. But, there are qualifiers. Although the cumulative life-table patency rates of infrapopliteal vessels is 47% at 5 years, many patients do not have acceptable venous conduit and the use of suboptimal conduit results in lower patency rates. Five-year patency rates below 25% are sometimes seen in patients with prosthetic graft material. In addition, the 30-day mortality for all patients undergoing infrainguinal arterial revascularization for threatened limbs can be as high as 6%, with major complication rates ranging from 20% to 50%.

While long-term results may be less durable, endovascular intervention for patients with lower extremity arterial disease continue to grow in popularity. Recent improvements in guidewire, catheter, stent, atherectomy technology, and catheter-based skills and device alternatives, have transformed the treatment of lower extremity peripheral arterial disease from a primarily open surgical bypass modality to one where endovascular treatment is typically attempted first and may be all that is required. Indeed, many interventionists who treat critical limb ischemia consider endovascular therapy as the first line of treatment in all levels, including infrapopliteal lesions involving tibial vessels. Although it has generally been reported that endovascular patency rates have been lower, limb salvage rates appear similar compared to open surgical bypass patients. In a meta-analysis of open surgical bypass of infrapopliteal arteries, the 1- and 3-year limb salvage rates were 89% and 82%, respectively. This is similar to the limb salvage rates achieved by endovascular treatments of infrapopliteal lesions, 86% and 82%. This is likely that patients with critical limb ischemia require the revascularization be patent long enough for wound healing.

When performing endovascular interventions, certain principles should be followed. First, at least one good distal outflow artery is preserved, so that open surgical bypass to the outflow artery can be performed if endovascular procedure failed. Second, the initially patent arterial segment should not be damaged during intervention. This can avoid unnecessary more distal bypass than would have been required. Third, important collateral circulation should be preserved. This allows patients to return to baseline clinical status if the treated arterial segments reocclude. When these principles are followed, recurrent arterial disease usually does not jeopardize future bypass options.

Key advantages of endovascular procedures include the ability to perform the procedure with the patients under sedation and local anesthesia without the need for general or spinal anesthesia. Perioperative complication rates are significantly reduced compared with open surgical bypasses. Endovascular treatment modalities can be performed without the need for acceptable conduits. The use of percutaneous access avoids the needs for lower extremity incisions, thereby eliminating wound complications. After percutaneous access, most patients are able to ambulate and return to preoperative functional status earlier. Endovascular interventions do not compromise future open bypass surgical options if there is restenosis or recurrence of symptoms.