What are the surgical management options for patients with severe peripheral vascular disease (PVD)?

Surgical Management Options for Severe Peripheral Vascular Disease

Surgical intervention is indicated for patients with severe peripheral vascular disease who have significant functional disability that is vocational or lifestyle limiting, who are unresponsive to exercise or pharmacotherapy, and who have a reasonable likelihood of symptomatic improvement. 1

Patient Selection for Surgical Management

Surgical management should be considered in the following scenarios:

• Lifestyle-limiting claudication despite 3 months of optimal medical therapy and exercise
• Chronic limb-threatening ischemia (CLTI)
• Acute limb ischemia
• Significant functional disability affecting quality of life

Preoperative Considerations

• A comprehensive cardiovascular risk evaluation is mandatory before major vascular surgical intervention 1
• Early recognition and referral to a vascular team is essential for limb salvage in CLTI 1
• Patients should be managed by a multidisciplinary vascular team 1

Surgical Options Based on Anatomical Location

1. Aortoiliac Occlusive Disease (Inflow Procedures)

• Aortobifemoral bypass: First-line surgical option for patients with hemodynamically significant aortoiliac disease who are suitable surgical candidates and unresponsive to or unsuitable for exercise, pharmacotherapy, or endovascular repair 1
• Iliac endarterectomy and aortoiliac/iliofemoral bypass: Recommended for unilateral disease or in conjunction with femoral-femoral bypass for bilateral iliac disease in patients unsuitable for aortobifemoral bypass 1
• Axillofemoral-femoral bypass: Limited use, only considered for chronic infrarenal aortic occlusion with severe claudication in patients who are not candidates for aortobifemoral bypass 1

2. Femoropopliteal Disease (Outflow Procedures)

• Above-knee popliteal bypass: Should be constructed with autogenous vein when possible (Level of Evidence: A) 1
• Below-knee popliteal bypass: Should be constructed with autogenous vein when possible (Level of Evidence: B) 1
• Synthetic grafts: Only reasonable for below-knee popliteal artery when no autogenous vein is available from ipsilateral or contralateral leg or arms 1

3. Infrapopliteal Disease (Tibial Arteries)

• Femoral-tibial artery bypass: Should be constructed with autogenous vein, including ipsilateral greater saphenous vein or other sources from leg or arm 1
• Composite sequential femoropopliteal-tibial bypass: Acceptable when no other form of bypass with adequate autogenous conduit is possible 1
• Prosthetic femoral-tibial bypass with adjunctive procedures: Consider when amputation is imminent and no autogenous vein is available 1

Surgical vs. Endovascular Approach

The choice between surgical and endovascular approaches should be based on:

• Anatomical considerations: Lesion location, morphology, and extent
• Patient factors: Surgical risk, comorbidities, life expectancy
• Conduit availability: Presence of suitable autogenous vein

For femoro-popliteal lesions:

• Open surgical approach should be considered when autologous vein (e.g., great saphenous vein) is available in patients with low surgical risk 1
• Endovascular treatment may be considered as first-line therapy in CLTI patients with increased surgical risk or inadequate autogenous veins 1

Special Considerations for CLTI

For patients with chronic limb-threatening ischemia:

• Revascularization should be performed as soon as possible 1
• Autologous veins are the preferred conduit for infra-inguinal bypass surgery 1
• In multilevel vascular disease, inflow obstructions must be eliminated when treating downstream lesions 1
• Infra-inguinal bypass may be considered in patients with good autologous veins and low surgical risk (<5% peri-operative mortality, >50% 2-year survival) 1

Postoperative Management and Follow-up

• All patients undergoing revascularization for CLTI should receive antiplatelet therapy indefinitely, unless contraindicated 1
• Regular follow-up (at least annually) is recommended to assess clinical and functional status, medication adherence, and limb symptoms 1
• For patients with autogenous vein bypasses, periodic evaluations for at least 2 years should include:
  • Assessment of claudication symptoms
  • Physical examination of proximal, graft, and outflow vessels
  • Duplex imaging of the entire graft length with velocity measurements 1

Common Pitfalls to Avoid

• Focusing only on limb symptoms while neglecting cardiovascular risk reduction 2
• Delaying revascularization in CLTI patients, which can lead to tissue loss and amputation
• Using synthetic grafts for femoral-tibial artery bypasses for claudication (contraindicated) 1
• Performing axillofemoral-femoral bypass for intermittent claudication outside very limited settings 1
• Neglecting regular follow-up after revascularization

Surgical management of severe PVD requires careful patient selection, appropriate technique selection based on anatomical considerations, and diligent postoperative care to optimize outcomes and reduce morbidity and mortality.