What are the indications for revascularization in patients with Peripheral Artery Disease (PAD)?

Indications for Revascularization in Peripheral Artery Disease

Revascularization in PAD is indicated for patients with lifestyle-limiting claudication who have had an inadequate response to guideline-directed medical therapy (including structured exercise therapy) and when the potential benefits outweigh the risks of intervention. 1

Primary Indications for Revascularization

Claudication (Chronic Symptomatic PAD)

• First-line approach: 3 months of optimal medical therapy and structured exercise therapy 1
• Revascularization indicated when:
  • Symptoms remain functionally limiting despite GDMT and structured exercise 1
  • Quality of life is significantly impaired 1
  • Risk-benefit assessment favors intervention 1
  • Patient has vocational or lifestyle-limiting disability 1

Chronic Limb-Threatening Ischemia (CLTI)

• Immediate revascularization is recommended for:
  • Ischemic rest pain 1
  • Non-healing lower-limb wounds (≥2 weeks duration) 1
  • Lower-limb gangrene 1
  • Hemodynamic criteria: ankle pressure <50 mmHg, toe pressure <30 mmHg, or TcPO2 <30 mmHg 1

Acute Limb Ischemia

• Emergent revascularization is required to preserve limb viability 2

Contraindications for Revascularization

• Asymptomatic PAD: Revascularization is not recommended 1
• Solely to prevent progression to CLTI: Not recommended as this has not been shown to alter natural history 1
• Inadequate risk-benefit ratio: When risks outweigh potential benefits 1
• CLTI with wounds: Exercise training is contraindicated 1

Decision-Making Algorithm for Revascularization

1. Confirm PAD diagnosis with ABI testing (≤0.9 confirms PAD) 2, 3

2. Classify severity:

   • Asymptomatic PAD → Medical therapy only
   • Claudication → Trial of GDMT + structured exercise for 3 months
   • CLTI → Prompt revascularization

3. For claudication after 3 months of GDMT:

   • Assess PAD-related quality of life 1
   • If symptoms persist and are functionally limiting → Consider revascularization
   • Evaluate risk-benefit ratio based on comorbidities and anatomical factors 1

4. Select revascularization approach based on:

   • Anatomical location of lesions
   • Lesion morphology (length, calcification, occlusion vs. stenosis)
   • Patient's surgical risk
   • Availability of autologous vein for bypass 1

Anatomical Considerations for Revascularization Approach

Aortoiliac Disease

• Endovascular approach preferred for focal lesions 1
• Balloon angioplasty with/without stenting for external iliac arteries 1
• Primary stenting for common iliac arteries 1

Femoropopliteal Disease

• Drug-eluting treatment as first-choice strategy 1
• Open surgical approach when autologous vein is available in low-risk patients 1
• Endovascular therapy for shorter lesions 1

Infrapopliteal Disease

• Primarily indicated for CLTI rather than claudication 1
• May be considered during femoro-popliteal revascularization in severe claudication 1

Important Clinical Considerations

• Multidisciplinary approach: Vascular team management is essential, especially for CLTI 1
• Post-revascularization risks: Patients who undergo revascularization are at increased risk for major adverse limb events (MALE) and may need additional procedures 1
• Conduit selection: Autologous veins are recommended over prosthetic grafts for infra-inguinal bypass 1, 4
• Multilevel disease: Inflow obstructions should be addressed when treating downstream lesions 1

Pharmacotherapy After Revascularization

• Antiplatelet therapy: Single antiplatelet or combination of low-dose rivaroxaban (2.5 mg BID) with aspirin (100 mg daily) in patients with high ischemic risk and non-high bleeding risk 1, 5
• Statin therapy: High-intensity statins for all PAD patients 6, 7
• Antihypertensive therapy: Target BP <140/90 mmHg (non-diabetics) or <130/80 mmHg (diabetics) 6

Regular follow-up at least annually is recommended to assess clinical status, medication adherence, and symptoms, with vascular imaging as needed 1.