Peripheral arterial disease surgery

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AHA/ACC Guidelines on Management of Lower Extremity PAD

Guidelines for Clinical Assessment of Lower Extremity PAD

Guidelines for Diagnostic Testing for suspected PAD

Guidelines for Screening for Atherosclerotic Disease in Other Vascular Beds in patients with Lower Extremity PAD

Guidelines for Medical Therapy for Lower Extremity PAD

Guidelines for Structured Exercise Therapy for Lower Extremity PAD

Guidelines for Minimizing Tissue Loss in Lower Extremity PAD

Guidelines for Revascularization of Claudication in Lower Extremity PAD

Guidelines for Management of CLI in Lower Extremity PAD

Guidelines for Management of Acute Limb Ischemial in Lower Extremity PAD

Guidelines for Longitudinal Follow-up for Lower Extremity PAD

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aarti Narayan, M.B.B.S [3]; Vishnu Vardhan Serla M.B.B.S. [4]; Rim Halaby

Overview

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]

Endovascular Revascularization Modalities

  • PTAC ( Percutaneous transluminal angioplasty)
  • Stents
  • Atherectomy
  • Laser
  • Cutting balloons
  • Thermal angioplasty
  • Fibrinolysis/Fibrinectomy[1]

Surgical Revascularization Modalities

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

  • Femoral-above the knee popliteal vein
  • Femoral-above the knee popliteal prosthetic
  • Femoral-below the knee popliteal vein
  • Femoral-below the knee popliteal prosthetic
  • Femoral-tibial vein
  • Femoral-tibial prosthetic
  • Composite sequential bypass
  • Femoral-tibial blind segment bypass
  • Profundaplasty[1]

Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations) : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines[2]

Surgery for CLI

Class I
"1.For individuals with combined inflow and outflow disease with CLI, inflow lesions should be addressed first. (Level of Evidence: B)"
"2.For individuals with combined inflow and outflow disease in whom symptoms of CLI or infection persist after inflow revascularization, an outflow revascularization procedure should be performed. (Level of Evidence: B)"
"3. Patients who have significant necrosis of the weight-bearing portions of the foot (in ambulatory patients), an uncorrectable flexion contracture, paresis of the extremity, refractory ischemic rest pain, sepsis, or a very limited life expectancy due to comorbid conditions should be evaluated for primary amputation of the leg. (Level of Evidence: C)"
Class III
"1.Surgical and endovascular intervention is not indicated in patients with severe decrements in limb perfusion (e.g., ABI <0.4) in the absence of clinical symptoms of CLI. (Level of Evidence: C)"

Endovascular Treatments for CLI

Class I
"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)"
"3. If it is unclear whether hemodynamically significant inflow disease exists, intra-arterial pressure measurements across suprainguinal lesions should be measured before and after the administration of a vasodilator. (Level of Evidence: C)"
Class IIa
"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)"

Preoperative Evaluation (DO NOT EDIT)[1]

Class I
"1. A preoperative cardiovascular risk evaluation should be undertaken in those patients with lower extremity PAD in whom a major vascular surgical intervention is planned. (Level of Evidence: B)"

Inflow Procedures: Aortoiliac Occlusive Disease in CLI Patients (DO NOT EDIT)[1]

Class I
"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]

Class I
"1. Bypasses to the above-knee popliteal artery should be constructed with autogenous saphenous vein when possible. (Level of Evidence: A)"
"2. Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible. (Level of Evidence: A)"
"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)"
"4. The tibial or pedal artery that is capable of providing continuous and uncompromised outflow to the foot should be used as the site of distal anastomosis. (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)"
Class IIa
"1. Prosthetic material can be used effectively for bypasses to the below-knee popliteal artery when no autogenous vein from ipsilateral or contralateral leg or arms is available. (Level of Evidence: B)"

Postsurgical Care in CLI Patients (DO NOT EDIT)[1]

Class I
"1. Unless contraindicated, all patients undergoing revascularization for CLI should be placed on antiplatelet therapy (see Sections 2.4.2 and 2.6.1.6), and this treatment should be continued indefinitely. (Level of Evidence: A). "
"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). "
"3. If infection, ischemic ulcers, or gangrenous lesions persist and the ABI is less than 0.8 after correction of inflow, an outflow procedure should be performed that bypasses all major distal stenoses and occlusions. (Level of Evidence: A). "
"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]

Class I
"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)"
Class IIa
"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)"

Surgery in Claudication (DO NOT EDIT)[1]

Class I
"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)"
Class III
"1. Surgical intervention is not indicated to prevent progression to limb-threatening ischemia in patients with intermittent claudication. (Level of Evidence: B)"
Class IIb
"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]

Class I
"1. Aortobifemoral bypass is beneficial for patients with vocational- or lifestyle-disabling symptoms and hemodynamically significant aortoiliac disease who are acceptable surgical candidates and who are unresponsive to or unsuitable for exercise, pharmacotherapy, or endovascular repair. (Level of Evidence: B)"
"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)"
Class III
"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)"
Class IIb
"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]

Class I
"1. Bypasses to the popliteal artery above the knee should be constructed with autogenous vein when possible. (Level of Evidence: A)"
"2. Bypasses to the popliteal artery below the knee should be constructed with autogenous vein when possible. (Level of Evidence: B)"
Class III
"1. Femoral-tibial artery bypasses with synthetic graft material should not be used for the treatment of claudication. (Level of Evidence: C)"
Class IIa
"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)"
Class IIb
"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]

Class I
"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)"

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B (2006). "ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation". Circulation. 113 (11): e463–654. doi:10.1161/CIRCULATIONAHA.106.174526. PMID 16549646. Retrieved 2012-10-09. Unknown parameter |month= ignored (help)
  2. Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L; et al. (2013). "Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 61 (14): 1555–70. doi:10.1016/j.jacc.2013.01.004. PMC 4492473. PMID 23473760.
  3. Bernstein EF, Rhodes GA, Stuart SH, Coel MN, Fronek A (1981). "Toe pulse reappearance time in prediction of aortofemoral bypass success". Annals of Surgery. 193 (2): 201–5. PMC 1345042. PMID 7469553. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)
  4. 4.0 4.1 Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM (2010). "Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy". Journal of Vascular Surgery. 51 (5 Suppl): 5S–17S. doi:10.1016/j.jvs.2010.01.073. PMID 20435258. Retrieved 2012-11-05. Unknown parameter |month= ignored (help)

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