What is the interventional treatment for Peripheral Vascular Disease (PVD)?

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Interventional Treatment for Peripheral Vascular Disease

For symptomatic PAD with impaired quality of life after 3 months of optimal medical therapy and exercise, revascularization should be considered, with the specific approach tailored to lesion location and morphology. 1

Initial Management Framework

Before considering intervention, patients with symptomatic PAD require a 3-month trial of optimal medical treatment (OMT) and supervised exercise therapy, followed by quality of life assessment. 1 Revascularization is NOT recommended solely to prevent progression to chronic limb-threatening ischemia (CLTI), and is NOT indicated in asymptomatic PAD. 1

Endovascular Interventions by Anatomic Location

Iliac Artery Lesions

Stenting is effective as primary therapy for both common and external iliac artery stenoses and occlusions. 1

  • For external iliac arteries: balloon angioplasty with or without stenting should be considered 1
  • For common iliac arteries: primary stenting should be considered 1
  • Provisional stent placement is indicated as salvage therapy for suboptimal balloon dilation results (persistent translesional gradient, residual stenosis >50%, or flow-limiting dissection) 1
  • Translesional pressure gradients (with and without vasodilation) should be obtained to evaluate stenoses of 50-75% diameter before intervention 1

Femoro-Popliteal Lesions

Drug-eluting treatment (drug-coated balloons or drug-eluting stents) should be considered as the first-choice strategy for femoro-popliteal lesions. 1

  • Endovascular therapy should be considered as the initial approach 1
  • An open surgical approach with autologous vein (e.g., great saphenous vein) should be considered when available in patients with low surgical risk 1
  • The effectiveness of atherectomy, cutting balloons, thermal devices, and lasers (except as salvage for suboptimal balloon dilation) is not well-established 1
  • Primary stent placement is NOT recommended in the femoral or popliteal arteries 1

Below-the-Knee (BTK) Arteries

In patients with severe intermittent claudication undergoing endovascular femoro-popliteal revascularization, treatment of BTK arteries may be considered in the same intervention if there is substantially impaired outflow. 1

  • The effectiveness of uncoated/uncovered stents, atherectomy, cutting balloons, thermal devices, and lasers (except as salvage therapy) is not well established 1
  • Primary stent placement is NOT recommended in tibial arteries 1

Chronic Limb-Threatening Ischemia (CLTI)

In CLTI patients, revascularization should be performed as soon as possible. 1

Surgical Approach for CLTI

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

Endovascular Approach for CLTI

Endovascular treatment may be considered as first-line therapy, especially in patients with increased surgical risk. 1

  • Recent data from the BASIL-2 trial showed superior outcomes with catheter-based intervention over surgical bypass for CLTI with infrapopliteal involvement 1
  • The BEST-CLI trial showed comparable amputation and mortality rates with endovascular revascularization versus bypass in patients lacking suitable saphenous vein conduit 1

Access Considerations

Transradial arterial access (TRA) has emerged as a transformative approach with distinct advantages including reduced bleeding complications, improved patient comfort, shorter time to ambulation, and reduced hospital stay. 1

  • TRA is limited to maximum 6-Fr sheath size in most patients 1
  • TRA offers lower vascular complication rates and favorable catheter angles for certain procedures 1
  • Transfemoral access accommodates larger equipment and offers more flexibility for complex interventions 1

Critical Contraindications

  • Endovascular intervention is NOT indicated if there is no significant pressure gradient across a stenosis despite flow augmentation with vasodilators 1
  • Endovascular intervention is NOT indicated as prophylactic therapy in asymptomatic patients 1

Adjunctive Medical Therapy

Treatment with combination rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) should be considered for patients with PAD and high ischemic risk, and non-high bleeding risk, including following lower-limb revascularization. 1

  • Clopidogrel 75 mg daily is indicated in patients with established PAD to reduce the rate of MI and stroke 2

Follow-Up

Regular follow-up at least once yearly is recommended, assessing clinical and functional status, medication adherence, limb symptoms, and cardiovascular risk factors, with duplex ultrasound assessment as needed. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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