Peripheral Artery Disease Compendium Circulation Research Compendium on Peripheral Artery Disease Epidemiology of Peripheral Artery Disease Pathogenesis of the Limb Manifestations and Exercise Limitations in Peripheral Artery Disease Lower Extremity Manifestations of Peripheral Artery Disease: The Pathophysiologic and Functional Implications of Leg Ischemia The Genetic Basis of Peripheral Arterial Disease: Current Knowledge, Challenges and Future Directions Modulating the Vascular Response to Limb Ischemia: Angiogenic and Cell Therapies Pharmacological Treatment and Current Management of Peripheral Artery Disease Endovascular Intervention for Peripheral Artery Disease Surgical Intervention for Peripheral Arterial Disease John Cooke, Guest Editor
Surgical Intervention for Peripheral Arterial Disease Shant M. Vartanian, Michael S. Conte
Abstract: The prevalence of peripheral arterial disease (PAD) is increasing worldwide, with recent global estimates exceeding 200 million people. Advanced PAD leads to a decline in ambulatory function and diminished quality of life. In its most severe form, critical limb ischemia, rest pain, and tissue necrosis are associated with high rates of limb loss, morbidity, and mortality. Revascularization of the limb plays a central role in the management of symptomatic PAD. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Nonetheless, surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease. Although there is little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability. As it stands, surgical revascularization remains the standard against which emerging percutaneous techniques are compared. This review summarizes the principles of surgical revascularization, patient selection, and expected outcomes, while highlighting areas in need of further research and technological advancement. (Circ Res. 2015;116:1614-1628. DOI: 10.1161/ CIRCRESAHA.116.303504.) Key Words: peripheral arterial disease
Principles of Revascularization: Clinical Indications and Patient Selection
■
vascular surgical procedures
3 categories: asymptomatic disease, intermittent claudication (IC) and limb-threatening ischemia (critical limb ischemia [CLI]). With rare exception (eg, to create an iliac conduit for a thoracic aortic endograft), reconstruction for occlusive disease is never indicated in asymptomatic patients. The clinical decision process for revascularization in IC and CLI is distinct and merits elaboration. Although the anatomic pattern of occlusive disease is a major factor in the revascularization strategy, it
The surgical management of patients with peripheral arterial disease (PAD) is derived from the wider context of the epidemiology and natural history of the disease, and the influence of coexisting medical conditions such as coronary artery disease, diabetes mellitus, and renal disease. The spectrum of clinical presentation of PAD is broad and can be classified into
Original received January 26, 2015; revision received March 23, 2015; accepted March 28, 2015. In February 2015, the average time from submission to first decision for all original research papers submitted to Circulation Research was 13.9 days. From the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco. Correspondence to Michael S. Conte, MD, Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Ave, Suite A-581, San Francisco, CA 94143-0222. E-mail [email protected] © 2015 American Heart Association, Inc. Circulation Research is available at http://circres.ahajournals.org
DOI: 10.1161/CIRCRESAHA.116.303504
1614
Vartanian and Conte Surgical Intervention for PAD 1615
Nonstandard Abbreviations and Acronyms ABI AIOD BASIL CFA CLI GSV IC PAD PTFE TASC
ankle-brachial indices aortoiliac occlusive disease Bypass versus Angioplasty in Severe Ischaemia of the Leg common femoral artery critical limb ischemia great saphenous vein intermittent claudication peripheral arterial disease polytetrafluoroethylene Trans-Atlantic Inter-Society Consensus
should be stressed that the physiological state of the patient and the status of the limb primarily determines the appropriateness and urgency of intervention for PAD.
Intermittent Claudication Although the cellular and biochemical changes in the limb with claudication are complex, symptoms of IC occur only during physical activity, when the metabolic demands of the muscles are not met by the capacity of the circulatory system.1,2 Many patients with PAD remain asymptomatic because their activity level does not exceed this threshold. In particular, patients with coexistent heart failure, severe pulmonary disease, or advanced musculoskeletal disease such as arthritis may never manifest symptoms despite having hemodynamics just above the inception of rest pain. Conversely, competitive cyclists may have symptoms of thigh claudication during exercise as a result of external iliac artery endofibrosis, despite having a normal pulse examination and normal anatomic imaging at rest.3,4 The classic symptoms of claudication are calf muscle aching, fatigue, or cramping, although it can also involve the buttocks, thigh or hip. The hallmark features are symptoms that are reproducibly elicited with physical activity and are alleviated during rest with abatement during a period of 10 to 15 minutes. A detailed history and a careful physical examination can help differentiate PAD from other causes of lower extremity pain such as spinal stenosis (pseudoclaudication), radiculopathy, arthritis, symptomatic Bakers cysts, benign nocturnal cramps, or other less common diagnoses. The principal disability in IC is limited exercise performance and walking ability. This translates into a subjective reduction in physical functioning and quality of life. Outside of special populations, the natural history of claudication is often stable during subsequent years. In a classic study from England, of the 1476 patients followed up for ≤10 years, only 11% of claudicants had a clinical deterioration during the observation period.5 These findings have been reiterated in numerous other reports.6,7 Hemodynamic assessment by ankle-brachial indices (ABI) suggests that some populations have a gradual deterioration over time, particularly those at the lowest strata of ankle pressures. Nevertheless, a decline in ABI does not necessarily translate into clinical deterioration, which may be a result of molecular and biochemical adaptation, gradual collateral network formation, a change in
the patient’s perception of their disability or the patient altering their gait or activity level to alleviate symptoms. In the absence of diabetes mellitus,
Surgical Intervention for Peripheral Arterial Disease Shant M. Vartanian, Michael S. Conte
Abstract: The prevalence of peripheral arterial disease (PAD) is increasing worldwide, with recent global estimates exceeding 200 million people. Advanced PAD leads to a decline in ambulatory function and diminished quality of life. In its most severe form, critical limb ischemia, rest pain, and tissue necrosis are associated with high rates of limb loss, morbidity, and mortality. Revascularization of the limb plays a central role in the management of symptomatic PAD. Concomitant with advances in the pathogenesis, genetics, and medical management of PAD during the last 20 years, there has been an ongoing evolution of revascularization options. The increasing application of endovascular techniques has resulted in dramatic changes in practice patterns and has refocused the question of which patients should be offered surgical revascularization. Nonetheless, surgical therapy remains a cornerstone of management for advanced PAD, providing versatile and durable solutions to challenging patterns of disease. Although there is little high-quality comparative effectiveness data to guide patient selection, existing evidence suggests that outcomes are dependent on definable patient factors such as distribution of disease, status of the limb, comorbid conditions, and conduit availability. As it stands, surgical revascularization remains the standard against which emerging percutaneous techniques are compared. This review summarizes the principles of surgical revascularization, patient selection, and expected outcomes, while highlighting areas in need of further research and technological advancement. (Circ Res. 2015;116:1614-1628. DOI: 10.1161/ CIRCRESAHA.116.303504.) Key Words: peripheral arterial disease
Principles of Revascularization: Clinical Indications and Patient Selection
■
vascular surgical procedures
3 categories: asymptomatic disease, intermittent claudication (IC) and limb-threatening ischemia (critical limb ischemia [CLI]). With rare exception (eg, to create an iliac conduit for a thoracic aortic endograft), reconstruction for occlusive disease is never indicated in asymptomatic patients. The clinical decision process for revascularization in IC and CLI is distinct and merits elaboration. Although the anatomic pattern of occlusive disease is a major factor in the revascularization strategy, it
The surgical management of patients with peripheral arterial disease (PAD) is derived from the wider context of the epidemiology and natural history of the disease, and the influence of coexisting medical conditions such as coronary artery disease, diabetes mellitus, and renal disease. The spectrum of clinical presentation of PAD is broad and can be classified into
Original received January 26, 2015; revision received March 23, 2015; accepted March 28, 2015. In February 2015, the average time from submission to first decision for all original research papers submitted to Circulation Research was 13.9 days. From the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco. Correspondence to Michael S. Conte, MD, Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Ave, Suite A-581, San Francisco, CA 94143-0222. E-mail [email protected] © 2015 American Heart Association, Inc. Circulation Research is available at http://circres.ahajournals.org
DOI: 10.1161/CIRCRESAHA.116.303504
1614
Vartanian and Conte Surgical Intervention for PAD 1615
Nonstandard Abbreviations and Acronyms ABI AIOD BASIL CFA CLI GSV IC PAD PTFE TASC
ankle-brachial indices aortoiliac occlusive disease Bypass versus Angioplasty in Severe Ischaemia of the Leg common femoral artery critical limb ischemia great saphenous vein intermittent claudication peripheral arterial disease polytetrafluoroethylene Trans-Atlantic Inter-Society Consensus
should be stressed that the physiological state of the patient and the status of the limb primarily determines the appropriateness and urgency of intervention for PAD.
Intermittent Claudication Although the cellular and biochemical changes in the limb with claudication are complex, symptoms of IC occur only during physical activity, when the metabolic demands of the muscles are not met by the capacity of the circulatory system.1,2 Many patients with PAD remain asymptomatic because their activity level does not exceed this threshold. In particular, patients with coexistent heart failure, severe pulmonary disease, or advanced musculoskeletal disease such as arthritis may never manifest symptoms despite having hemodynamics just above the inception of rest pain. Conversely, competitive cyclists may have symptoms of thigh claudication during exercise as a result of external iliac artery endofibrosis, despite having a normal pulse examination and normal anatomic imaging at rest.3,4 The classic symptoms of claudication are calf muscle aching, fatigue, or cramping, although it can also involve the buttocks, thigh or hip. The hallmark features are symptoms that are reproducibly elicited with physical activity and are alleviated during rest with abatement during a period of 10 to 15 minutes. A detailed history and a careful physical examination can help differentiate PAD from other causes of lower extremity pain such as spinal stenosis (pseudoclaudication), radiculopathy, arthritis, symptomatic Bakers cysts, benign nocturnal cramps, or other less common diagnoses. The principal disability in IC is limited exercise performance and walking ability. This translates into a subjective reduction in physical functioning and quality of life. Outside of special populations, the natural history of claudication is often stable during subsequent years. In a classic study from England, of the 1476 patients followed up for ≤10 years, only 11% of claudicants had a clinical deterioration during the observation period.5 These findings have been reiterated in numerous other reports.6,7 Hemodynamic assessment by ankle-brachial indices (ABI) suggests that some populations have a gradual deterioration over time, particularly those at the lowest strata of ankle pressures. Nevertheless, a decline in ABI does not necessarily translate into clinical deterioration, which may be a result of molecular and biochemical adaptation, gradual collateral network formation, a change in
the patient’s perception of their disability or the patient altering their gait or activity level to alleviate symptoms. In the absence of diabetes mellitus,
