What is the current best practice regarding vein bypass first versus best medical treatment (BMT) first revascularization strategies?

From the Guidelines

The current best practice for revascularization strategies in patients with coronary artery disease or peripheral arterial disease favors a multidisciplinary team approach, considering patient-centered decisions, and incorporating patient preferences and goals. For patients with coronary artery disease, the 2021 ACC/AHA/SCAI guideline recommends surgical revascularization for patients with significant left main disease to improve survival, while percutaneous revascularization is a reasonable option for selected patients with low-to-medium anatomic complexity of CAD and left main disease 1. In contrast, for patients with peripheral arterial disease, the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline suggests an endovascular-first approach for most patients, reserving bypass surgery for specific cases, such as those with extensive disease, long occlusions, or critical limb ischemia with tissue loss 1. Key considerations in the decision-making process include:

• Lesion complexity and location
• Patient factors, including age, comorbidities, functional status, and life expectancy
• Availability of autologous vein conduits for surgical bypass
• The goal of revascularization, whether to relieve symptoms, improve wound healing, or prevent amputation Regardless of the chosen strategy, optimal medical therapy, including antiplatelet agents, statins, smoking cessation, and risk factor modification, remains the foundation of treatment. This individualized approach balances immediate procedural success with long-term durability based on anatomical and patient-specific considerations. The use of a radial artery as a surgical revascularization conduit is preferred versus the use of a saphenous vein conduit to bypass the second most important target vessel with significant stenosis after the left anterior descending coronary artery, due to superior patency, reduced adverse cardiac events, and improved survival 1. Preoperative assessment of the adequacy of the great saphenous vein conduit is important when developing a patient-specific revascularization strategy for critical limb ischemia, and can be performed using duplex ultrasound or point-of-care ultrasound 1. Ultimately, the choice of revascularization strategy should be guided by a thorough assessment of the patient's condition, careful consideration of the potential risks and benefits, and a commitment to providing patient-centered care.

From the Research

Vein Bypass First Versus Best Indoor Vascular Treatment First Revascularisation Strategies

• The current best practice regarding vein bypass first versus best indoor vascular treatment first revascularisation strategies is not explicitly stated in the provided studies, but some insights can be gathered from the available evidence.
• According to 2, optimal medical management of peripheral arterial disease is critical and should include lifestyle measures such as smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet, as well as pharmacological components like blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins.
• The study 3 emphasizes the importance of implementing best medical treatment (BMT) in patients with carotid artery stenosis, which includes lifestyle measures and pharmacological components similar to those mentioned in 2.
• Regarding antiplatelet therapy, 4 suggests that achieving a balance between ischemic and bleeding risk is important in managing patients on antiplatelet therapy, and consultation with the patient's cardiologist, physician, and/or vascular surgeon is recommended before interrupting or withholding this treatment modality.
• The study 5 found that antiplatelet therapy with aspirin or with aspirin plus dipyridamole had a beneficial effect on primary patency of peripheral bypass grafts compared to placebo or no treatment, particularly in prosthetic grafts.
• However, the study 6 found that ticagrelor did not significantly reduce vein graft occlusion 1 year after coronary artery bypass graft surgery compared to conventional aspirin therapy.

Key Considerations

• The importance of optimal medical management and best medical treatment in patients with peripheral arterial disease and carotid artery stenosis cannot be overstated.
• Antiplatelet therapy plays a crucial role in preventing thrombosis after peripheral arterial bypass surgery, but the optimal regimen remains unclear.
• The choice of revascularisation strategy, whether vein bypass first or best indoor vascular treatment first, should be individualized based on patient-specific factors and guided by a multidisciplinary team of healthcare professionals.
• Further research is needed to determine the most effective revascularisation strategies and to clarify the role of antiplatelet therapy in preventing graft occlusion and improving outcomes.