Selecting Patients for Open Surgical or Endovascular Treatment of Lower Extremity Occlusive Disease Timur Sarac and Jennifer Ellis After confirmation of peripheral arterial disease (PAD) by physical examination and Doppler ankle-to-brachial indices (ABIs), further radiologic testing, such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), or intraarterial angiogram, may be performed to further localize and potentially treat the culprit lesion. These imaging studies should be done with the goal of proceeding with treatment. Patient Selection for Treatment and Therapeutic Options Treatment options for PAD are multifaceted and typically include a combination of medical therapy and surgery, either endovascular surgery, open surgery, or a hybrid combination. However, to achieve optimal benefit when selecting patients for therapy, it is important to know which patients will require treatment for limb salvage, in addition, which patients are at higher risk for medical or postoperative complications. In almost every significant study treating PAD, patients with diabetes and kidney failure have inferior results with open or endovascular therapy. In addition, wound complications are reported to occur in as many as 40% of patients with an open lower extremity surgical procedure. The type of intervention offered commonly depends of the presentation of PAD and the degree of symptoms. On initial diagnosis, patients have no symptoms, exercise-induced claudication, lifestyle-limiting claudication, rest pain, or tissue loss. The location and degree of disease also affects selection of treatment. The Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Artery Disease (TASC) is a collaborative group of 14 medical and surgical specialties from Europe and North America. In 2000, this group published the TASC guidelines for treating PAD. TASC II was published in 2007 and is an updated version of the guidelines that include femoral–popliteal disease. TASC developed a classification system for aortoiliac and femoral–popliteal lesions based on anatomic location and severity of disease. Type A and B femoral–popliteal lesions are easily treated with angioplasty with or without stents, and conventional open surgery has been recommended for more complex lesions. There are similar recommendations for aortoiliac lesions. With the advent of newer balloons, wires, catheters, and devices, more complex lesions are now being attacked with endovascular therapy. Conventional open surgery still achieves outstanding results and should be considered depending on the specific patient. Endovascular Interventions If patients have continued lifestyle-limiting claudication despite aggressive modification of risk factors, pharmacomedical therapy, and exercise programs, endovascular or surgical intervention may be required. With increasing knowledge about the disease process, patients often request an endovascular intervention as a first-line therapy. The decision of whether to offer a patient an endovascular intervention for claudication is based on the patient’s overall health and on the location and severity of the occlusion. For example, a short common iliac and/or superficial femoral artery stenosis or occlusion can easily be treated with balloon angioplasty and stenting and can achieve excellent long term-results and relief of symptoms. One major advantage of this approach is that it avoids a major operation and allows the patient an opportunity for quicker recuperation. Patient preference often plays an important role in this decision. Additionally, it is not uncommon to offer a patient a hybrid approach of iliac or superficial femoral artery (SFA) intervention in conjunction with femoral endarterectomy and profundaplasty. The success of endovascular treatment of complex longer lesions has improved, and it now rivals open surgery for aortoiliac occlusive disease but not yet for femoral popliteal occlusive disease. Patients with rest pain and tissue loss have been less commonly offered endovascular therapy because of the gravity of their disease process. Standard therapy for this cohort of patients has been to offer a surgical bypass to allow maximum pulsatile flow to the extremity. Nevertheless, recent success has challenged this paradigm for limb salvage. The rationale for this approach is that it is less invasive, and wound complications remain a significant concern. Hard data for this approach came from the BASIL trial (Bypass versus Angioplasty in Severe Ischaemia of the Leg), which demonstrated that for patients with critical limb ischemia, amputation-free survival was similar in patients who randomized to surgery first compared to those who randomized to angioplasty first. On subsequent analysis, the similarity lasted for 2 years, but patients in the surgery-first arm had better outcomes beyond this time period. The specific type of treatment offered depends on the physician, and the metric in which each device’s outcomes are reported have not been standardized. Although reevaluating older approaches such as atherectomy, or using new therapy such as cryoplasty have been popular, there is no level I evidence that clearly identifies one form of treatment as better than balloon angioplasty and stenting. Nevertheless, a selective approach to using each device can offer a satisfactory limb-salvage option to patients who are unfit for open surgical procedures. For example, bifurcation lesions in a debilitated patient can achieve satisfactory results with atherectomy. Long-term patency with angioplasty and stenting for SFA stenosis can reach 65% at 1 year and can reach 90% for common iliac artery stenosis. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. 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Selecting Patients for Open Surgical or Endovascular Treatment of Lower Extremity Occlusive Disease Timur Sarac and Jennifer Ellis After confirmation of peripheral arterial disease (PAD) by physical examination and Doppler ankle-to-brachial indices (ABIs), further radiologic testing, such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), or intraarterial angiogram, may be performed to further localize and potentially treat the culprit lesion. These imaging studies should be done with the goal of proceeding with treatment. Patient Selection for Treatment and Therapeutic Options Treatment options for PAD are multifaceted and typically include a combination of medical therapy and surgery, either endovascular surgery, open surgery, or a hybrid combination. However, to achieve optimal benefit when selecting patients for therapy, it is important to know which patients will require treatment for limb salvage, in addition, which patients are at higher risk for medical or postoperative complications. In almost every significant study treating PAD, patients with diabetes and kidney failure have inferior results with open or endovascular therapy. In addition, wound complications are reported to occur in as many as 40% of patients with an open lower extremity surgical procedure. The type of intervention offered commonly depends of the presentation of PAD and the degree of symptoms. On initial diagnosis, patients have no symptoms, exercise-induced claudication, lifestyle-limiting claudication, rest pain, or tissue loss. The location and degree of disease also affects selection of treatment. The Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Artery Disease (TASC) is a collaborative group of 14 medical and surgical specialties from Europe and North America. In 2000, this group published the TASC guidelines for treating PAD. TASC II was published in 2007 and is an updated version of the guidelines that include femoral–popliteal disease. TASC developed a classification system for aortoiliac and femoral–popliteal lesions based on anatomic location and severity of disease. Type A and B femoral–popliteal lesions are easily treated with angioplasty with or without stents, and conventional open surgery has been recommended for more complex lesions. There are similar recommendations for aortoiliac lesions. With the advent of newer balloons, wires, catheters, and devices, more complex lesions are now being attacked with endovascular therapy. Conventional open surgery still achieves outstanding results and should be considered depending on the specific patient. Endovascular Interventions If patients have continued lifestyle-limiting claudication despite aggressive modification of risk factors, pharmacomedical therapy, and exercise programs, endovascular or surgical intervention may be required. With increasing knowledge about the disease process, patients often request an endovascular intervention as a first-line therapy. The decision of whether to offer a patient an endovascular intervention for claudication is based on the patient’s overall health and on the location and severity of the occlusion. For example, a short common iliac and/or superficial femoral artery stenosis or occlusion can easily be treated with balloon angioplasty and stenting and can achieve excellent long term-results and relief of symptoms. One major advantage of this approach is that it avoids a major operation and allows the patient an opportunity for quicker recuperation. Patient preference often plays an important role in this decision. Additionally, it is not uncommon to offer a patient a hybrid approach of iliac or superficial femoral artery (SFA) intervention in conjunction with femoral endarterectomy and profundaplasty. The success of endovascular treatment of complex longer lesions has improved, and it now rivals open surgery for aortoiliac occlusive disease but not yet for femoral popliteal occlusive disease. Patients with rest pain and tissue loss have been less commonly offered endovascular therapy because of the gravity of their disease process. Standard therapy for this cohort of patients has been to offer a surgical bypass to allow maximum pulsatile flow to the extremity. Nevertheless, recent success has challenged this paradigm for limb salvage. The rationale for this approach is that it is less invasive, and wound complications remain a significant concern. Hard data for this approach came from the BASIL trial (Bypass versus Angioplasty in Severe Ischaemia of the Leg), which demonstrated that for patients with critical limb ischemia, amputation-free survival was similar in patients who randomized to surgery first compared to those who randomized to angioplasty first. On subsequent analysis, the similarity lasted for 2 years, but patients in the surgery-first arm had better outcomes beyond this time period. The specific type of treatment offered depends on the physician, and the metric in which each device’s outcomes are reported have not been standardized. Although reevaluating older approaches such as atherectomy, or using new therapy such as cryoplasty have been popular, there is no level I evidence that clearly identifies one form of treatment as better than balloon angioplasty and stenting. Nevertheless, a selective approach to using each device can offer a satisfactory limb-salvage option to patients who are unfit for open surgical procedures. For example, bifurcation lesions in a debilitated patient can achieve satisfactory results with atherectomy. Long-term patency with angioplasty and stenting for SFA stenosis can reach 65% at 1 year and can reach 90% for common iliac artery stenosis. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease In-Situ Treatment of Aortic Graft Infection with Prosthetic Grafts and Allografts Treatment of Acute Upper Extremity Venous Occlusion Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
