Selecting Patients for Open Surgical or Endovascular Treatment of Lower Extremity Occlusive Disease

Patient Selection for Treatment and Therapeutic Options

Treatment options for PAD are multifaceted and typically include a combination of medical therapy and surgery, either endovascular surgery, open surgery, or a hybrid combination. However, to achieve optimal benefit when selecting patients for therapy, it is important to know which patients will require treatment for limb salvage, in addition, which patients are at higher risk for medical or postoperative complications. In almost every significant study treating PAD, patients with diabetes and kidney failure have inferior results with open or endovascular therapy. In addition, wound complications are reported to occur in as many as 40% of patients with an open lower extremity surgical procedure.

The type of intervention offered commonly depends of the presentation of PAD and the degree of symptoms. On initial diagnosis, patients have no symptoms, exercise-induced claudication, lifestyle-limiting claudication, rest pain, or tissue loss.

The location and degree of disease also affects selection of treatment. The Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Artery Disease (TASC) is a collaborative group of 14 medical and surgical specialties from Europe and North America. In 2000, this group published the TASC guidelines for treating PAD. TASC II was published in 2007 and is an updated version of the guidelines that include femoral–popliteal disease. TASC developed a classification system for aortoiliac and femoral–popliteal lesions based on anatomic location and severity of disease. Type A and B femoral–popliteal lesions are easily treated with angioplasty with or without stents, and conventional open surgery has been recommended for more complex lesions. There are similar recommendations for aortoiliac lesions. With the advent of newer balloons, wires, catheters, and devices, more complex lesions are now being attacked with endovascular therapy. Conventional open surgery still achieves outstanding results and should be considered depending on the specific patient.