Peripheral Artery Disease: Surgical Therapy

Guideline recommendations [S3 guideline]:

• For revascularization, preference should be given to endovascular treatment (performed through the blood vessels – from the inside, so to speak) if the same symptomatic improvement can be achieved in the short term and long term as with vascular surgery. (Recommendation grade A, evidence class 1) Note: For TASC-A and TASC-B lesion, endovascular treatment with good openness rate is recommended.For TASC-C and TASC-D lesions, open surgical treatment (see below) is recommended.
• In patients with critical ischemia, inflow and subsequent outflow lesions should be treated by interventional therapy whenever possible. (Grade of recommendation A, class of evidence 2).
• Implantation of stents in cross-joint vessel segments (common femoral artery, popliteal artery) is generally not indicated. (Consensus recommendation)
• Implantation of stents in inter-joint vascular segments may be considered in the stage of critical limb ischemia with impending limb loss and lack of other therapeutic options. (Consensus Recommendation)
• In patients with intermittent claudication, supervised exercise programs to increase walking distance (see “Further Therapy” below) are similarly effective to endovascular or vascular surgery. (Evidence class 1)
• In patients with critical limb ischemia (CLI), endovascular treatment should be given preference if the same symptomatic improvement can be achieved in the short and long term as with vascular surgery. (Recommendation grade A, evidence class 2).
• Bypass surgery:
  • Administration of antiplatelet agents in peripheral bypass surgery should be started preoperatively. It should be continued after surgical procedures or hybrid procedures and, unless contraindications arise, should be continued long-term. (Recommendation grade A, evidence class 1).
  • Administration of unfractionated heparin should be started immediately before placement of vascular clamps in all patients. Anticoagulation should be maintained by repeated bolus administration perioperatively. (Consensus recommendation)
  • When femoro-popliteal bypasses are created, the great saphenous vein (consisting of one segment if possible) should be used, both in cases of intermittent claudication and critical ischemia, because it is superior to alternative bypass material. (Supragenual: Recommendation grade A, evidence class 1; Infragenual: Recommendation grade A; Evidence grade 4).
  • In critical ischemia, suprapopliteal bypasses should be made of autologous vein because their durability is significantly higher than that of prosthetic bypasses. (Grade of recommendation A, class of evidence 1).

Indications for surgery (revascularizing procedures):

• PAVK in stage III and IV

1st order

• Percutaneous transluminal angioplasty (PTA) – in this method, the affected vessel is dilated from the inside with a balloon catheter and, if necessary, held open with a support (called a stent) (stenting); Indication: long-stretch femoro-popliteal lesionsWhen the TASC II criteria are observed, the interventional results are comparable to vascular surgery results, at least in the medium term. Notice: After percutaneous revascularization, DAPT (dual antiplatelet therapy; dual antiplatelet therapy) limited to one month is recommended initially; after surgical revascularization, antiplatelet monotherapy can be started immediately [2017 ESC Guidelines].
• Bypass surgery-creation of a bypass circuit using a previously harvested vein.
• Amputation (Ultima Ratio)

Estimation of the risk of amputation by determining the transcutaneous partial pressure of oxygen (pO2).

Notice: FDA information on paclitaxel-eluting balloons and paclitaxel-releasing stents for the treatment of peripheral arterial disease: increased mortality (death rate).The FDA did not specify in the final recommendations what the magnitude of the mortality increase is; new paclitaxel-releasing stents outside of trials can only be used in exceptional cases and after individual consideration and education. Note: The BfArM assesses this equally.In a health services research analysis based on German health insurance data from BEK, long-term mortality was not increased under paclitaxel-eluting stents and balloons. Further references

• In patients with peripheral arterial disease (PAVD) and critical limb ischemia (reduced blood flow to the extremities), endovascular intervention saves the patient from amputation as well as open surgical revascularization (open vascular bypass).Endovascular intervention had the following advantages:
  • Patients were more comfortable after initial endovascular therapy.
    • Longer free of amputation and also survived longer
    • Less likely to have a major amputation/amputation above the ankle region (above or below the knee)