Since the time of the first edition of this book by Yeung and King in 2006,1 the practice of peripheral vascular medicine has evolved into a more effective and well-organized discipline. Most would agree that practice guidelines for the management of patients with peripheral arterial disease (PAD) first published in 2006,2 with updates in 20113 and 2013,4 and 2016, coupled with the rapid innovation in technology (Table 54-1), clinical research, and continuing educational programs, have provided the backbone for the remarkable progress in this field.
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Vascular physicians representing a variety of medical, surgical, and imaging societies continue to work tirelessly to improve the quality of care, such as by writing guidelines for the management of patients with PAD and defining medical competence in the diagnosis and treatment of PAD.5 Since 2005, several thousands of physicians, mostly cardiologists and vascular surgeons, have become credentialed in vascular imaging interpretation after passing the Registered Physician in Vascular Interpretation examination.6 The American Board of Vascular Medicine also offers certification that recognizes expertise in both general vascular medicine and endovascular specialty.
In addition, hospitals have implemented plans to protect patients and health care personnel from the frequently prolonged radiation exposure in the catheterization laboratory at the time of treatment. The PVI Registry of the American College of Cardiology further demonstrates ongoing efforts to improve care by voluntarily tracking the outcomes of peripheral vascular procedures.7 The ultimate common goal is to deliver a safe, effective, sustained, and valuable service to the increasing number of PAD patients.
This chapter provides interventional cardiology specialists with practical information and general guidance for the evaluation and treatment of patients with PAD of the lower extremities. In part, this chapter replicates what the Emory interventional cardiology trainees are expected to learn during their years of training and represents a compilation of knowledge extracted from practice guidelines, relevant publications, and our personal experience.
As in other areas of medicine, treatment recommendations can be controversial and open to revision informed by research. Most controversy lies in the choice of treatment and the effectiveness of a variety of stents, balloons, and medical devices currently used in patients with symptomatic PAD.
For example, perhaps the most exemplary case of practice variation among vascular specialists is the treatment of a totally occluded, 15-cm-long, moderately calcified superficial femoral artery (SFA). The SFA is one the most commonly affected vessels in patients with PAD, and surgery is the gold standard therapy for these long calcified lesions when symptoms persist despite risk factor modification, supervised exercise, and drug therapy with cilostazol. Complex SFA lesions are increasingly treated with endovascular techniques that, although less invasive, nonetheless carry the risk of reintervention due to restenosis of the index vessel (Fig. 54-1).
FIGURE 54-1
A. Angiogram of a patient with critical limb ischemia and an open wound in the right foot from a long total occlusion of the right superficial femoral artery (SFA). B. Complex endovascular revascularization of the right SFA using a Pioneer reentry device, atherectomy, balloons, and distal filter protection. C. Suboptimal angiographic results of the right SFA from unexpected thrombotic complication. Thrombus extending into the profunda artery, treated with Angiojet and systemic anticoagulation. D. Good blood flow to the right popliteal and trifurcation vessels, with subsequent healing of the ulcer in the right foot, despite suboptimal angiographic results shown in C. E. Restenosis of the right SFA 4 months later, diagnosed by surveillance arterial duplex ultrasound and confirmed by angiogram. F and G. Right SFA restenosis treated with repeat atherectomy. H. Patent popliteal artery and trifurcation vessels (not shown). The patient remains asymptomatic with a healed ulcer in the right foot 15 months after the initial procedure. The patient undergoes periodic surveillance arterial duplex ultrasound examinations to monitor for patency and to monitor the mild SFA vessel wall dilatation after atherectomy.
If an endovascular approach is preferred over surgery, several questions remain: Should the vascular obstruction undergo debulking with atherectomy first after using a reentry device, or be treated with a drug-coated balloon or stent instead, assuming no procedure-related complications? If the decision is made to place a stent, should it be a self-expanding nitinol stent, drug-eluting stent, or a flexible stent graft?
While the AHA/ACC guidelines from 2013 indicate that endovascular intervention is recommended as the preferred revascularization option for focal femoropopliteal arterial lesions (Transatlantic Intersociety Consensus [TASC] type A),4 the 2016 guidelines do not restrict lesion characteristics.
Future editions of this chapter and the management of PAD will benefit from innovation in endovascular procedures and medical devices and the availability of new drugs and outcome data from comparative effectiveness research, but until then, we must do what we believe is best, safest, and most effective for each patient.
Patients seen in a cardiology practice should be asked about symptoms of PAD and examined for the consequences of this prevalent disease, especially those who are age 50 years and older and have risk factors for atherosclerosis, such as tobacco use, diabetes, hypertension, chronic kidney disease, and hyperlipidemia. Elevated plasma homocysteine and C-reactive protein levels are also considered risk factors for developing PAD. In addition, all adults 70 years of age and older should be evaluated for PAD (Class I recommendation from American College of Cardiology [ACC]/American Heart Association [AHA] guidelines). Since the vast majority of patients with PAD have atypical symptoms, clinicians and health care personnel caring for these patients must have a high level of suspicion for vascular disease. Lower extremity claudication with typical effort-related limb pain occurs in only 11% of patients.8 Observing the patient’s gait and asking family members about the patient’s walking limitations may help diagnose PAD.
The physical examination should include a detailed assessment of the femoral, popliteal, dorsalis pedis, and posterior tibial pulses as absent (0), diminished (1), normal (2), or bounding (3), keeping in mind that about 10% of the population has congenital absence of the dorsalis pedis or posterior tibial pulses. If unable to palpate pulses, find them using a handheld Doppler device. However, the presence of pulses does not exclude PAD. Document the presence or absence of bruits in the carotids, subclavian, abdominal, and femoral artery territories. Be sure to obtain blood pressure in both arms to exclude subclavian artery stenosis; a >10 mm Hg systolic pressure difference between arms should be considered abnormal and suspicious for arterial stenosis in the upper extremities.
Examine the feet for tissue loss and previous amputations, which could indicate critical limb ischemia. Patients with critical limb ischemia often have rest pain and ischemic ulcers in the toes and forefoot. On physical exam, they may also have calf atrophy, thickening of the toenails, scaly/shiny skin from loss of subcutaneous tissue, loss of hair, pallor of the affected limb, diminished or loss of pulse, and skin that is cold to the touch.
If an ischemic ulcer is present, document the location, size in centimeters, presence of infection, and severity of tissue loss. The Wagner grade of the wound/gangrene provides an in-depth description of the affected limb with critical ischemia:
Grade 0: pre- or postulcerative lesion
Grade 1: partial-/full-thickness ulcer
Grade 2: probing to tendon or joint capsule or fascia
Grade 3: deep ulcer with abscess or osteomyelitis
Grade 4: partial foot gangrene
Grade 5: whole foot gangrene
Serial pictures of the wound are often helpful to monitor treatment progress.
Once the clinical diagnosis of limb ischemia is established, findings in the physical examination, such as the presence or absence of sensory loss and muscle weakness, and results of the Doppler signal in the arterial and venous systems will help determine if the limb is viable, threatened, or irreversibly damaged. Reviewing all operative notes from any previous surgical or endovascular revascularization procedures will also guide management decisions.
Critical limb ischemia with chronic rest pain, nonhealing ulcer, and gangrene requires a catheter angiogram and often revascularization procedures to minimize the risk of short-term amputation. These patients can be easily identified by physical examination, and the diagnosis can be confirmed with simple physiologic studies. The ankle pressure is likely to be <50 mm Hg, and the toe pressure is likely to be <30 mm Hg.
Acute limb ischemia with sudden-onset pain in the lower extremity accompanied by paresthesia and loss of motor function constitutes a vascular emergency. Patients require intravenous heparin and immediate evaluation and treatment to determine the level of vessel obstruction and restore the blood flow to the affected limb. Endovascular treatment using catheter-based thrombolysis and thombectomy is preferred over open surgery (Fig. 54-2).
FIGURE 54-2
Acute simultaneous thrombosis of the right superficial femoral artery (A) and the left popliteal artery (B) with ischemic pain in both legs after a brief interruption of warfarin given for atrial fibrillation. Blood flow was restored in both legs (C and D) after urgent endovascular treatment using distal filter protection, Angiojet, atherectomy, balloons, and systemic anticoagulation.
Ankle-brachial index (ABI) is a simple, cost-effective, noninvasive method for diagnosing PAD in the office setting. There is no formal contraindication for this test, but some patients may have intolerable pain in their legs and arms during cuff inflation. A detailed description of equipment preparation, procedure, calculation, and interpretation has been published.9 Although it is standard to calculate the ABI by dividing the highest systolic tibial artery pressure by the highest systolic brachial pressure, we find it clinically helpful to calculate and report the ABI for both the dorsalis pedis and the posterior tibial arteries.10 The normal ABI range is 1.0 to 1.4, borderline range is 0.91 to 0.99, and abnormal range is 0.90 or less.11 ABI <0.50 at rest suggests multilevel PAD, whereas ABI <0.30 defines critical limb ischemia.
Current ACC/AHA guidelines recommend ABI testing in patients with exertional leg symptoms, nonhealing wounds, age 65 years and older, or age 50 years and older with a history of smoking or diabetes.4 Individuals with suspected lower extremity PAD who have effort-related symptoms, diminished pulses, femoral bruit, nonhealing wounds, gangrene, or sudden-onset ischemic leg symptoms or signs of acute limb ischemia should also undergo a resting ABI measurement. According to the Appropriate Use Criteria for lower extremity testing published by the ACC/AHA in 2012,12 repeat ABIs in patients with known PAD is justified for new or worsening symptoms of claudication, but surveillance ABIs every 12 months or greater were deemed to have uncertain benefit.
Postexercise ABI using a treadmill should be considered in patients with typical or atypical claudication to diagnose PAD when the resting ABI is normal (0.91-1.4). Abnormal treadmill response is defined as a drop of the postexercise ankle pressure >20 mm Hg compared with the resting pressure. Toe-tip exercise testing with pre- and postexercise ABI could be offered as an alternative to a motorized treadmill test if the patient cannot walk or if a treadmill is not available. Unfortunately, toe-tip exercise may not provoke symptoms in patients with significant PAD, and this alternative mode of exercise test is not accepted as a Current Procedural Terminology substitute code to the standard motorized treadmill by the Centers for Medicare and Medicaid Services.13
Toe pressure measures digital perfusion and is the numerator of the toe-brachial index (TBI) calculation, which is the ratio of toe systolic pressure to brachial systolic pressure. The normal TBI range is 0.80 to 0.90; TBI <0.7 is abnormal,11 and TBI <0.2 is generally associated with ischemic rest pain or ischemic ulceration. TBI measurement is most helpful in patients with ABIs greater than 1.4 due to arterial wall calcification. Toe pressures provide valuable information in patients with small vessel arterial disease and give an estimate of the wound healing potential of the feet.14 Toe pressure <40 mm Hg suggests low perfusion pressure insufficient for wound healing, while toe pressure >60 mm Hg makes wound healing more likely. An absolute variation of greater than 0.15 in the ABI and/or TBI is considered significant when done serially.
Analysis of the segmental pressures and pulse volume recording (PVR) establish both the physiologic significance of PAD obstruction and the segment of disease. PVR is often used to monitor primary and secondary vessel patency after revascularization, whereas PVR and TBI are used to diagnose and assess the severity of PAD in patients with noncompressible pedal pulses. Noncompressible vessels due to calcification generally have ABIs greater than 1.4 and are frequently encountered in patients with diabetes and chronic renal disease and the elderly. If ankle pressure is elevated due to vessel calcification, the amplitude of the resting waveform PVR should be compared with the PVR after exercise; the severity of the amplitude reduction provides valuable information regarding the significance of the PAD. However, in our opinion, analysis of the pulsed wave Doppler waveforms is more reliable than the PVR.
In addition to ABI, toe pressures, and TBI, interventional cardiologists who perform endovascular peripheral procedures should become proficient in the indication for and interpretation of duplex ultrasound technology. This portable, noninvasive imaging technology provides both anatomic and physiologic information about the arterial and venous vasculature. Duplex ultrasound is used in the initial diagnosis of PAD and is the preferred surveillance imaging modality for patency after revascularization procedures. Advantages of duplex ultrasound compared with magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) for initial diagnosis and postrevascularization follow-up include the convenience and lower cost for the patient and the ease of the examination with no need for contrast. However, the quality of the duplex ultrasound examination is highly operator dependent.
Patients undergoing lower extremity revascularization with endovascular techniques require a baseline ABI and a duplex ultrasound examination of the treated vascular segment within 1 month of the procedure. In addition to the baseline study, we routinely repeat the ABIs and duplex ultrasound examinations at 3 and 6 months after the endovascular intervention to monitor for patency of the target vessel site. Patients are at highest risk for restenosis during the first 6 months following the procedure, and symptoms of recurrent disabling claudication may occur too late, after (re) occlusion of the index lesion. Repeat revascularization of a totally occluded artery from restenosis is expected to be difficult and time consuming, while also exposing both the patient and the operators to excessive direct radiation. Early detection of physiologic (ABI/PVR) or anatomic (duplex ultrasound) signs of significant restenosis will permit planning for reintervention, before progression to a total occlusion.
Patients previously treated for critical limb ischemia are especially vulnerable for restenosis and atherosclerosis progression. Therefore, this high-risk cohort requires periodic, at least semiannual, clinical and physiologic/imaging evaluation by an integrated team of vascular care professionals, including podiatrists, with the ultimate goal of preventing recurrent ischemic pain, skin ulceration, and amputation.
New multidetector technology has made CTA a reasonable alternative to catheter angiography in detecting the location and severity of stenosis in PAD patients. However, MRA with gadolinium, which provides pristine angiographic-like images without radiation and without the need for iodine contrast, received a stronger recommendation as a diagnostic method in the 2013 ACC/AHA guidelines (Class I vs Class IIb). The 2016 guidelines give Duplex ultrasound, CTA, and MRA the same Class I recommendation for the detection of the location and severity of PAD stenosis. Table 54-2 lists the advantages and disadvantages of both imaging tests.
| Advantages | Disadvantages | |
|---|---|---|
| MRA | No iodine contrast, no radiation | Inability to detect calcium, metal artifact, rarely allergic reaction to gadolinium, very rarely nephrogenic systemic fibrosis caused by the gadolinium (less common with the newer agents) |
| CTA | Detection of calcium | Need for iodine contrast and radiation exposure |
An underrecognized benefit of both is the ease with which these images can be shown and explained to the patient as well as the practicality of discussing angiographic findings and treatment options at the time of the outpatient follow-up office visit. With the development of these 2 technologies, the need for conventional diagnostic lower extremity angiograms has decreased, thus lessening the risk associated with invasive procedures. In our practice, we prefer MRA over a diagnostic catheter angiogram as the initial diagnostic procedure (Fig. 54-3).
Symptomatic patients with poor arterial perfusion who experience lifestyle-limiting or disabling claudication, ischemic pain at rest, or ischemic tissue loss benefit from a digital subtraction catheter angiogram, with an aim of correcting the vascular obstruction. Not all symptomatic patients with PAD need a complete aortogram with bilateral lower extremity runoff, and some require a more selective angiogram to limit the amount of contrast administered.
The choice of arteries imaged (abdominal aorta, right/left iliac, femoral, popliteal, tibioperoneal trunk, anterior tibial, posterior tibial, and peroneal arteries) and the vascular access site (femoral, brachial, and radial) depend not only on findings from the history and physical examination but also on the patient’s comorbidities and previous revascularization procedures. Variables such as renal function, the intended treatment (endovascular vs open surgical revascularization), and heart failure are a few of the many factors that influence planning the catheter angiogram in patients with symptomatic PAD. A diagnostic abdominal aortogram with a bilateral lower extremity runoff generally requires the use of approximately 100 to 150 mL of contrast—20 mL administered for the abdominal angiogram, 30 mL for the iliac angiograms in 2 views, and 70 to 100 mL for the lower extremity runoff. A selective single lower extremity angiogram can be done with less than 50 mL of diluted contrast.
Renal function must be assessed with a serum creatinine in all patients undergoing contrast exposure before scheduling an angiogram. Renal insufficiency should alert the interventionalist to carefully reevaluate the need for a test using contrast and to review and adjust the patient’s medications before the catheter angiogram. Administer intravenous fluids before contrast exposure to minimize risk of renal injury, and monitor renal function after the endovascular procedure. A duplex ultrasound of the abdominal aorta, iliac arteries, and arteries of the lower extremities before the angiogram could help better plan the diagnostic and endovascular revascularization procedures, such as limiting diluted contrast exclusively to the symptomatic vascular segment. A reliable, high-quality, noninvasive vascular laboratory with both imaging and physiologic testing is of utmost importance for the optimal management of patients with PAD and especially those affected with renal disease (Figs. 54-4 and 54-5).
FIGURE 54-4
The arterial duplex ultrasound of this patient with disabling claudication and severe chronic kidney disease predicted the angiographic findings and facilitated the revascularization procedure. The arterial duplex ultrasound shows a totally occluded proximal superficial femoral artery (SFA) with a “nubbin” at the ostium and a low echogenicity plaque in the most proximal SFA segment (A and B). The low echogenicity suggests a soft plaque with a high lipid content at the proximal end of the SFA occlusion. Poor Doppler signal in the proximal right SFA confirms absence of flow (B). The mid SFA is reconstituted by a collateral vessel (C). The distal end of the occluded SFA at the site of the collateral vessel has strong echogenicity, likely from a calcified and dense “hard” fibrous plaque (C and D). The result of the arterial duplex ultrasound facilitated the planning and performance of the right SFA revascularization procedure, as seen in Figure 54-5. CFA, common femoral artery.
FIGURE 54-5
The occluded right superficial femoral artery (SFA) by duplex ultrasound, with a “nubbin” and a proximal soft and hard distal plaque of the patient in Figure 54-4 was confirmed by angiogram (A). The soft plaque in the proximal end of the occluded right SFA was easily crossed with a Viance catheter without dissection (B), and the “hard” fibrous plaque at the distal end of the SFA occlusion was crossed with a 0.035-inch stiff Terumo straight glide wire, advanced through an angled KMP catheter (C), with excellent angiographic results and no complications (D). The crossing wire used with the Viance catheter first entered the collateral vessel in the mid SFA. This reference point in the mid SFA, also seen in the arterial duplex ultrasound (Fig. 54-4, C and D), facilitated the reentry into the distal SFA through the dense fibrous cap by simply pointing the KMP catheter and wire away from the collateral vessel and into the true SFA lumen.
The presence of heart failure could also influence the angiographic technique, because left ventricular dysfunction limits hydration with intravenous fluids before and after contrast exposure and also because the patient may not be able to lay flat during and after the procedure. If feasible, a radial or brachial artery access approach may be preferable in patients with heart failure.
Heart disease is prevalent in patients with PAD and should not be overlooked. It is good practice to exclude ischemic heart disease and heart failure before performing a diagnostic angiogram and treatment of the lower extremities. There is high coexistence of coronary artery disease and cerebrovascular disease with PAD. Knowing the left ventricular function and anticipating the tolerance to intravenous fluids can prevent heart failure decompensation. Knowledge of left ventricular function is also needed before prescribing cilostazol for symptomatic arterial disease, because heart failure with reduced ventricular systolic function is a contraindication for cilostazol use.
Patients with PAD who are on anticoagulation medications for chronic atrial fibrillation or for mechanical heart valves with a vitamin K antagonist are specially challenging candidates for catheter angiogram, mainly due to the potential risk of hemorrhage and arterial thromboembolism, even during heparin bridging. A careful discussion with the patient during the consent process, weighing the risks and benefits of the procedure, is needed, and an effort must be made to do the angiogram and the endovascular treatment during the same session. Noninvasive imaging studies, preferably with MRA, are of great value for planning the vascular treatment in patients with preserved renal function and no metal devices other than the mechanical valve, although new metal cardiac devices such as implantable cardioverter-defibrillators and pacemakers are now felt to be safe for magnetic resonance imaging (MRI).15 Duplex arterial ultrasound performed before the angiogram is a very good alternative to other imaging modalities, since it has the advantages of no contrast, no radiation, no contraindication with metal hardware, and lower cost.
A limited catheter angiogram and endovascular revascularization are likely to be scheduled on the same day for symptomatic patients with focal disease localized to 1 extremity as indicated by the clinical and noninvasive vascular examination. This same combined approach, but on different days, is common in staged procedures, with the angiogram and endovascular revascularization performed first to correct the inflow disease (ie, iliac stenosis), followed by treatment of the outflow (femoropopliteal artery stenosis) on a separate day. Treatment of the outflow segment may not be needed if the patient has complete or near-complete resolution of the symptoms of vascular insufficiency after treatment of the inflow vascular segment.
Staged interventions have the advantage of limiting the amount of contrast and radiation exposure to the patient. New hand-held injection devices, such as the AVERT system (Osprey Medical, Minnetonka, MN), reduce the amount of contrast injected during angiographic procedures without sacrificing the quality of the image and may help protect patients from contrast-induced nephropathy.16 At Emory University, we routinely use an 8-mL syringe with a manifold and use diluted (50:50) contrast to minimize the risk of kidney injury.
The angiographic technique is also determined by the presence or absence of femoral arterial access and by prior vascular interventions with stents and surgical grafts. The radial or brachial artery approach is often used in patients with severely stenosed or occluded common femoral or iliac arteries (Fig. 54-6), severe disease, or total occlusion of the distal abdominal aorta as well as in patients who have undergone prior vascular bypasses. Radial artery access is also convenient when patients are unable to lay flat or use the urinal during strict postprocedure bed rest, since this access allows patients to get up sooner than the femoral access approach and with lower risk of bleeding complications. However, arm access should be avoided in patients with arteriovenous shunts for hemodialysis.
FIGURE 54-6
Successful endovascular intervention of a 100% ostial left common iliac artery (CIA) using the left radial artery access approach for treatment of rest foot pain and abnormal physiologic studies with ankle-brachial index (ABI) in the critical limb ischemia range at 0.17 and ankle pressure of 32 mm Hg (A-D). Aortoiliac angiogram from the right common femoral artery (CFA) shows stents in both CIAs with occluded left iliac artery at the ostium (B). Crossing of the 100% left iliac artery with a 4-Fr vertebral catheter along with an exchanged length 0.035-inch straight stiff Terumo glide wire, advanced from the left radial artery (C). The occluded left CIA stents were treated with balloon angioplasty and a new self-expanding stent in the left external iliac artery (not shown). Repeat physiologic studies 2 weeks after treatment of the inflow segment revealed significant improvement of the ABI from 0.17 to 0.55; however, the patient continued to have disabling pain in the left foot and the decision was made to treat the outflow stenosis in the left superficial femoral artery (SFA) using the right CFA and the contralateral access approach (F and G). Staged endovascular revascularization of the left SFA with directional atherectomy and adjunctive balloon angioplasty resulted in resolution of the pain in the left leg and further improvement of the physiologic studies (H). Notice the improvement of the pulse volume recording (PVR) waveforms and photoplethysmography (PPG) of the left toe as well (H).
The left radial artery side is a better option than the right side due to the closer proximity to the distal abdominal aorta. A 4 Fr × 135 cm long pigtail catheter is available for a diagnostic lower extremity catheter angiogram from the left radial artery. The radial access allows not only a complete diagnostic angiogram, from the abdominal aorta down into the distal vessels, but also allows moving ahead with the endovascular treatment on the same day, as long as the equipment used is compatible with a 6-Fr sheath system and the needed equipment reaches the arterial site to be treated. If a 7-Fr sheath is needed, brachial or femoral artery access is preferable.
The descriptions and classifications of lesion and vessel characteristics that we will use for the remainder of the chapter are as follows.
Translesional Gradient (pullback gradient performed with a ≤4-Fr small lumen catheter for ambiguous 50%-70% range artery stenosis)
Degree of Lesion Calcification (criteria used at Emory University based on fluoroscopy at the lesion site)
Lesion Length
Angiographic Outcome After Endovascular Intervention
Primary patency: patent target lesion with no restenosis after intervention
Primary assisted patency: patent target lesion following reintervention for restenosis
Secondary patency: patent target lesion following reintervention of reocclusion
(In our opinion, this division is confusing, and lesions that restenose or occlude should be considered as restenosis.)
Endovascular or open surgical revascularization is justified for patients who experience lifestyle-limiting or disabling claudication despite adequate medical treatment with supervised exercise program and medications, as long as there is a reasonable likelihood of symptomatic improvement with a favorable risk-benefit ratio. Intervention is mandatory in patients with acute limb ischemia and critical limb ischemia for limb salvage.
An exemption to the symptom-driven rule should be considered in patients with severe but asymptomatic (or minimally symptomatic) iliac artery stenosis, because revascularization with a stent has a favorable risk-benefit ratio and progression to total occlusion could complicate treatment. Revascularization for asymptomatic but severe PAD below the inguinal ligament is currently debatable and should be individualized for each patient.
Patients with symptomatic PAD in the critical limb ischemia group (Rutherford categories 4, 5, and 6) should undergo prompt revascularization to avoid amputation or to convert a possible major amputation to a limited amputation. In acute limb ischemia, revascularization treatment should be immediate.
We believe that the majority of patients with symptomatic occlusive disease of the arteries of the lower extremities can be successfully treated with endovascular techniques. Table 54-3 denotes a few exceptions for which open surgical revascularization could be considered as the first line of treatment. However, none of these situations constitute an absolute contraindication to endovascular therapy, and the final decision is based on operator expertise and patient preference. It is always a good practice for the interventional cardiologist to review the patient’s clinical history and angiographic findings with a vascular surgeon, especially in difficult cases, with the aim of achieving consensus on the best revascularization treatment approach.
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