Is surgical intervention medically indicated for a patient with chronic limb-threatening ischemia of the left leg, presenting with ischemic rest pain, severe claudication, and significant occlusive arterial disease?

Surgical Revascularization is Medically Indicated for This Patient

This patient with chronic limb-threatening ischemia (CLTI) presenting with ischemic rest pain, distal SFA occlusion, and suitable great saphenous vein conduit should undergo femoral-popliteal bypass surgery with autogenous vein. 1, 2

Clinical Justification

This patient meets all criteria for CLTI requiring urgent revascularization:

• Ischemic rest pain present for 3 weeks (exceeding the 2-week threshold for chronic limb-threatening ischemia) 1
• Documented hemodynamically significant occlusive disease (distal SFA occlusion on arterial duplex) 1
• Dopplerable left pedal pulse indicating severely compromised perfusion 1
• Progressive symptoms (claudication advancing to rest pain) indicating deteriorating limb viability 1

Revascularization should be considered the primary approach to treatment of patients with CLTI rather than primary amputation, as surgical reconstruction carries 0-6% mortality versus 4-30% mortality for major amputation, with significantly better quality of life outcomes. 1

Surgical Approach is Superior to Endovascular Therapy

For this patient with available great saphenous vein (>3.5mm documented on venous ultrasound), surgical bypass is the preferred initial treatment:

• The BEST-CLI trial demonstrated that surgical revascularization with autogenous vein resulted in significantly lower rates of major adverse limb events or death compared to endovascular therapy (42.6% vs 57.4%, hazard ratio 0.68, P<0.001) in patients with adequate saphenous vein conduit 2
• Bypasses to the below-knee popliteal artery should be constructed with autogenous vein when possible (Class I, Level of Evidence A) 1
• The left great saphenous vein measuring over 3.5mm is suitable for bypass, meeting quality criteria for optimal conduit 1

Procedural Specifications

The proposed left femoral to below-knee popliteal bypass with reversed great saphenous vein is appropriate:

• The most distal artery with continuous flow from above and without stenosis >20% should be used as the point of origin for distal bypass 1
• The tibial or pedal artery capable of providing continuous and uncompromised outflow to the foot should be used as the site of distal anastomosis 1
• Reversed, nonreversed, and in situ vein bypass grafts all perform equally well, so the choice of reversed technique is acceptable 3

Inflow Assessment Required

Before proceeding with outflow revascularization, inflow disease must be evaluated and addressed if present:

• The patient requires CTA to assess inflow and exclude additional occlusive disease as documented in the clinical note 1
• For individuals with combined inflow and outflow disease with CLTI, inflow lesions should be addressed first (Class I, Level of Evidence B) 1
• The imaging shows patent iliacs with mild atherosclerosis and patent right external iliac artery stent, suggesting adequate inflow, but CTA confirmation is prudent 1

Preoperative Requirements

Prior to surgery, the following must be completed:

• Preoperative cardiovascular risk evaluation should be undertaken in patients with lower extremity PAD undergoing major vascular surgical intervention (Class I, Level of Evidence B) 1
• The carotid ultrasound showing only mild bilateral stenosis does not require intervention before lower extremity revascularization 1

Contraindications to Primary Amputation

This patient does NOT meet criteria for primary amputation:

• Primary amputation is indicated only for patients with significant necrosis of weight-bearing portions of the foot, uncorrectable flexion contracture, paresis, refractory ischemic rest pain after revascularization attempts, sepsis, or very limited life expectancy (Class I, Level of Evidence C) 1
• This patient has none of these contraindications to revascularization and should proceed with limb salvage 1

Common Pitfalls to Avoid

• Do not delay revascularization - the 3-week duration of rest pain indicates urgent need for intervention to prevent progression to tissue loss 1
• Do not proceed with endovascular therapy first when adequate saphenous vein is available, as surgical outcomes are superior 2
• Do not perform outflow revascularization without confirming adequate inflow - obtain CTA as planned 1
• Do not use prosthetic graft when autogenous vein is available, as vein grafts have superior patency rates for below-knee bypasses 1

Postoperative Management

Following successful revascularization:

• Antiplatelet therapy should be continued indefinitely unless contraindicated 4
• Duplex-based graft surveillance should be implemented to detect stenoses before graft failure 3
• Patients should be evaluated at least twice annually by a vascular specialist due to high recurrence rates 4, 5