Peripheral arterial disease surgery: Difference between revisions

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Latest revision as of 14:02, 31 October 2016

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

↑ ^1.00 ^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)
↑ 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.
↑ 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)
↑ ^4.0 ^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)

Template:WikiDoc Sources

[pmid16549646-1] 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)

[pmid23473760-2] 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.

[pmid7469553-3] 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)

[pmid20435258-4] 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)

[1]

[2]

[3]

[4]

@@ Line 7: / Line 7: @@
 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]].
-==Indications for Revascularization==
+==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
+** 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.
+** 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.
@@ Line 19: / Line 20: @@
 ====Acute Limb Ischemia====
-*All patients with acute limb [[ischemia]] must have an '''urgent''' anatomic evaluation of the PAD lesion and a prompt revascularization.<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
+*All patients with acute limb [[ischemia]] must have an urgent anatomic evaluation of the PAD lesion and a prompt revascularization.<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-==Endovascular vs Surgical Intervention==
+===Endovascular vs Surgical Intervention===
-===Intermittent Claudication===
+====Intermittent Claudication====
-*'''Endovascular interventions''' are usually the initial revascularization strategies for patients with [[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.
+*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===
+====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.
@@ Line 35: / Line 36: @@
 *Life threatening [[ischemia]], infected lesions, [[gangrene]] may require amputation with or without need for revascularization.
-===Acute Limb Ischemia===
+====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<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>.
+* When the limb is not viable, amputation is done.<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-===The Choice of the Revascularization Intervention Based on TASC Classification===
+====The Choice of the Revascularization Intervention Based on TASC Classification====
-''For detailed information regarding the TASC classification please click '''[[Peripheral arterial disease classification|here]]'''.''
+''For detailed information regarding the TASC classification, click [[Peripheral arterial disease classification|here]].''
-====Iliac Lesions====
+=====Iliac Lesions=====
-* '''Endovascular revascularization''' is the intervention of choice in patients with '''TASC type A 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).
+** 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'''.
+* 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:
+** 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
@@ Line 54: / Line 55: @@
 ***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.
+* 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====
+=====Femoral Lesions=====
-* '''Endovascular revascularization''' is the intervention of choice in patients with '''TASC type A femoropopliteal 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
+** TASC type A femoropopliteal lesions is defined as a single stenosis less than 3 cm of the superficial femoral artery or popliteal artery.
-popliteal artery.
+* Surgical revascularization is the intervention of choice in patients with TASC type D femoropopliteal lesions.
-* '''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.
-** '''TASC type D femoropopliteal lesions''' is defined as complete common femoral artery or superficial femoral artery
+* As for TASC type B femoropopliteal lesions and TASC type C femoropopliteal lesions, the choice between endovascular and surgical revascularization is not definite.<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-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.<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-==Endovascular Revascularization Modalities==
+===Endovascular Revascularization Modalities===
 *PTAC ( Percutaneous transluminal angioplasty)
 *[[Stent|Stents]]
@@ Line 74: / Line 73: @@
 *Fibrinolysis/Fibrinectomy<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-==Surgical Revascularization Modalities==
+===Surgical Revascularization Modalities===
-*Patients suffering from combined inflow and outflow diseases should have correction of the inflow problems first.
+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 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.
+*A correction of the inflow problems decreases the risk of distal graft thrombosis when distal revacularization is needed.
-===Vascular Surgical Procedures for Inflow Improvement===
+====Vascular Surgical Procedures for Inflow Improvement====
 *Aortobifemoral bypass
 *Aortoiliac or aortofemoral bypass
@@ Line 87: / Line 86: @@
 *Axillofemoral-femoral bypass
-===Vascular Surgical Procedures for Outflow Improvement===
+====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 vein
-*Femoral-Tibial prosthetic
+*Femoral-tibial prosthetic
 *Composite sequential bypass
-*Femoral-Tibial blind segment bypass
+*Femoral-tibial blind segment bypass
 *Profundaplasty<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref>
-==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)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref><ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-10}}</ref>==
+==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<ref name="pmid23473760">{{cite journal| author=Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss L et al.| title=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. | journal=J Am Coll Cardiol | year= 2013 | volume= 61 | issue= 14 | pages= 1555-70 | pmid=23473760 | doi=10.1016/j.jacc.2013.01.004 | pmc=4492473 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23473760  }} </ref>==
-===Critical Limb Ischemia: Endovascular and Open Surgical Treatment for Limb Salvage (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref><ref name="pmid21959305">{{cite journal |author= |title=2011 ACCF/AHA Focused Update of the Guideline for the Management of patients with peripheral artery disease (Updating the 2005 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines |journal=[[Circulation]] |volume=124 |issue=18 |pages=2020–45 |year=2011 |month=November |pmid=21959305 |doi=10.1161/CIR.0b013e31822e80c3 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21959305 |accessdate=2012-10-10}}</ref>===
+==Surgery for CLI==
+{|class="wikitable"
+|-
+| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''For individuals with combined inflow and outflow disease with CLI, inflow lesions should be addressed first.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|-
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+{|class="wikitable"
+|-
+|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
+|-
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|}
+==Endovascular Treatments for CLI==
 {|class="wikitable"
 |-
@@ Line 106: / Line 124: @@
 | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' For individuals with combined inflow and outflow disease with critical limb ischemia, inflow lesions should be addressed first. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.<ref name="pmid7469553">{{cite journal |author=Bernstein EF, Rhodes GA, Stuart SH, Coel MN, Fronek A |title=Toe pulse reappearance time in prediction of aortofemoral bypass success |journal=[[Annals of Surgery]] |volume=193 |issue=2 |pages=201–5 |year=1981 |month=February |pmid=7469553 |pmc=1345042 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0003-4932&volume=193&issue=2&spage=201 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.<ref name="pmid7469553">{{cite journal |author=Bernstein EF, Rhodes GA, Stuart SH, Coel MN, Fronek A |title=Toe pulse reappearance time in prediction of aortofemoral bypass success |journal=[[Annals of Surgery]] |volume=193 |issue=2 |pages=201–5 |year=1981 |month=February |pmid=7469553 |pmc=1345042 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0003-4932&volume=193&issue=2&spage=201 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |}
@@ Line 115: / Line 133: @@
 | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.<ref name="pmid20435258">{{cite journal |author=Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM |title=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=[[Journal of Vascular Surgery]] |volume=51 |issue=5 Suppl |pages=5S–17S |year=2010 |month=May |pmid=20435258 |doi=10.1016/j.jvs.2010.01.073 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(10)00233-8 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.<ref name="pmid20435258">{{cite journal |author=Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM |title=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=[[Journal of Vascular Surgery]] |volume=51 |issue=5 Suppl |pages=5S–17S |year=2010 |month=May |pmid=20435258 |doi=10.1016/j.jvs.2010.01.073 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(10)00233-8 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.<ref name="pmid20435258">{{cite journal |author=Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM |title=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=[[Journal of Vascular Surgery]] |volume=51 |issue=5 Suppl |pages=5S–17S |year=2010 |month=May |pmid=20435258 |doi=10.1016/j.jvs.2010.01.073 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(10)00233-8 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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.<ref name="pmid20435258">{{cite journal |author=Bradbury AW, Adam DJ, Bell J, Forbes JF, Fowkes FG, Gillespie I, Ruckley CV, Raab GM |title=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=[[Journal of Vascular Surgery]] |volume=51 |issue=5 Suppl |pages=5S–17S |year=2010 |month=May |pmid=20435258 |doi=10.1016/j.jvs.2010.01.073 |url=http://linkinghub.elsevier.com/retrieve/pii/S0741-5214(10)00233-8 |accessdate=2012-11-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 126: / Line 144: @@
 | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' A [[Preoperative_cardiac_risk_assessment|preoperative cardiovascular risk evaluation]] should be undertaken in those patients with lower extremity PAD in whom a major vascular surgical intervention is planned. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 136: / Line 154: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' When surgery is to be undertaken, aortobifemoral bypass is recommended for patients with symptomatic, hemodynamically significant, aorto-bi-iliac disease requiring intervention. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' When surgery is to be undertaken, aortobifemoral [[bypass]] is recommended for patients with symptomatic, [[hemodynamically]] significant, aorto-bi-iliac disease requiring intervention. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 152: / Line 170: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Bypasses to the above-knee popliteal artery should be constructed with autogenous saphenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Bypasses]] to the above-knee [[popliteal artery]] should be constructed with autogenous saphenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Bypasses]] to the below-knee [[popliteal artery]] should be constructed with autogenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 178: / Line 196: @@
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 188: / Line 206: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''. <nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 [[ABI]]s. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''. <nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' If [[infection]], [[ischemic]] [[ulcer]]s, 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 [[occlusion]]s. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 [[ABI]]s at rest and after exercise for at least 2 years after [[implantation]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''. <nowiki>"</nowiki>
 |}
@@ Line 210: / Line 228: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Long-term patency of infrainguinal [[bypass]] grafts should be evaluated in a surveillance program, which should include an interval vascular history, resting [[ABI]]s, [[physical examination]], and a [[duplex ultrasound]] at regular intervals if a venous conduit has been used.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 222: / Line 240: @@
 |-
 |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
-|}
-=== Endovascular Treatment for Claudication (DO NOT EDIT)<ref name="pmid16549646">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=113 |issue=11 |pages=e463–654 |year=2006 |month=March |pmid=16549646 |doi=10.1161/CIRCULATIONAHA.106.174526 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=16549646 |accessdate=2012-10-09}}</ref> ===
-{|class="wikitable"
-|-
-| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]]
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Translesional pressure gradients (with and without vasodilation) should be obtained to evaluate the significance of angiographic iliac arterial stenoses of 50% to 75% diameter before intervention. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Stenting is effective as primary therapy for common iliac artery stenosis and occlusions. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
-|-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Stenting is effective as primary therapy in external iliac artery stenoses and occlusions. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|}
-{|class="wikitable"
-|-
-|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]]
-|-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Endovascular intervention is not indicated if there is no significant pressure gradient across a stenosis despite flow augmentation with vasodilators. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Primary stent placement is not recommended in the femoral, popliteal, or tibial arteries. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' Endovascular intervention is not indicated as prophylactic therapy in an asymptomatic patient with lower extremity PAD. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|}
-{|class="wikitable"
-|-
-| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]]
-|-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Stents (and other adjunctive techniques such as lasers, cutting balloons, atherectomy devices, and thermal devices) can be useful in the femoral, popliteal, and tibial 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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
-|}
-{|class="wikitable"
-|-
-| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]]
-|-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 wellestablished.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
-|-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |}
@@ Line 289: / Line 249: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 297: / Line 257: @@
 |-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Surgical intervention is not indicated to prevent progression to limb-threatening ischemia in patients with intermittent claudication. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Surgical intervention is not indicated to prevent progression to limb-threatening [[ischemia]] in patients with [[intermittent claudication]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 305: / Line 265: @@
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 315: / Line 275: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 326: / Line 286: @@
 |-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 334: / Line 294: @@
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 344: / Line 304: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Bypasses to the popliteal artery above the knee should be constructed with autogenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' [[Bypass]]es to the [[popliteal artery]] above the knee should be constructed with autogenous vein when possible. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 |-
@@ Line 355: / Line 315: @@
 |-
-|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Femoral-tibial artery bypasses with synthetic graft material should not be used for the  treatment of claudication. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Femoral-tibial artery bypasses with synthetic graft material should not be used for the  treatment of [[claudication]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |}
@@ Line 363: / Line 323: @@
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
 |}
@@ Line 371: / Line 331: @@
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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). ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |-
-|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
+|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
 |}
@@ Line 384: / Line 344: @@
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 [[ABI]]s at rest and after exercise. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |-
-| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
+| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 [[ABI]]s at rest and after [[exercise]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
 |}
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Peripheral arterial disease surgery: Difference between revisions

Latest revision as of 14:02, 31 October 2016

Overview

Surgery

Indications for Revascularization

Intermittent Claudication

Critical Limb Ischemia

Acute Limb Ischemia

Endovascular vs Surgical Intervention

Intermittent Claudication

Critical Limb Ischemia

Acute Limb Ischemia

The Choice of the Revascularization Intervention Based on TASC Classification

Iliac Lesions

Femoral Lesions

Endovascular Revascularization Modalities

Surgical Revascularization Modalities

Vascular Surgical Procedures for Inflow Improvement

Vascular Surgical Procedures for Outflow Improvement

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

Endovascular Treatments for CLI

Preoperative Evaluation (DO NOT EDIT)[1]

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

Outflow Procedures:Infrainguinal Disease in CLI Patients (DO NOT EDIT)[1]

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

Prior Limb Arterial Revascularization in PAD Patients (DO NOT EDIT)[1]

Surgery in Claudication (DO NOT EDIT)[1]

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

Outflow Procedures: Infrainguinal Disease (DO NOT EDIT)[1]

Follow-up after Vascular Surgical Procedures (DO NOT EDIT)[1]

References

Navigation menu

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]

Preoperative Evaluation (DO NOT EDIT)^[1]

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

Outflow Procedures:Infrainguinal Disease in CLI Patients (DO NOT EDIT)^[1]

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

Prior Limb Arterial Revascularization in PAD Patients (DO NOT EDIT)^[1]

Surgery in Claudication (DO NOT EDIT)^[1]

Inflow Procedures: Aortoiliac Occlusive Disease (DO NOT EDIT)^[1]

Outflow Procedures: Infrainguinal Disease (DO NOT EDIT)^[1]

Follow-up after Vascular Surgical Procedures (DO NOT EDIT)^[1]