What are the options for revascularization (revasc) for infrapopliteal peripheral vascular disease (PVD)?

Revascularization Options for Infrapopliteal Peripheral Vascular Disease

Primary Recommendation

For patients with critical limb-threatening ischemia (CLTI) and infrapopliteal disease, bypass surgery using autogenous saphenous vein is the preferred revascularization strategy, providing superior long-term patency and limb salvage compared to endovascular approaches. 1 Endovascular intervention should be reserved for patients at high surgical risk, those lacking suitable vein conduit, or those with stenotic lesions and short occlusions. 1

Treatment Algorithm Based on Clinical Presentation

For Claudication (Intermittent Symptoms)

• Revascularization is NOT recommended for isolated infrapopliteal disease causing claudication. 1, 2 The usefulness of endovascular procedures for claudication from isolated infrapopliteal disease is unknown (Class IIb, Level C-LD). 1, 2

• Revascularization solely to prevent progression to CLTI is contraindicated (Class III: Harm), as progression rates are only 10-15% over 5 years and procedural risks outweigh hypothetical benefits. 1, 2

• Isolated infrapopliteal disease is an uncommon cause of claudication; most claudication results from more proximal disease. 1

For Critical Limb-Threatening Ischemia (Rest Pain, Tissue Loss, Gangrene)

• Infrapopliteal revascularization is mandatory for limb salvage in CLTI. 1 Early recognition of tissue loss and/or infection with referral to a vascular team is essential. 1

• Complete arterial network assessment with CTA/MRA and digital subtraction angiography (DSA) down to the plantar arches is required before revascularization. 1, 2

Surgical Revascularization Options

Bypass with Autogenous Vein (Gold Standard)

• Bypass using the great saphenous vein is indicated as first-line treatment for infrapopliteal revascularization in CLTI (Class I, Level A). 1 This provides superior long-term patency and leg survival, particularly for long occlusions of crural arteries. 1, 2

• The ipsilateral greater saphenous vein is the preferred conduit; if unavailable, use contralateral leg or arm veins. 2

• The bypass should be as short as possible to optimize patency. 1

When to Choose Surgical Over Endovascular

• Long occlusions of crural arteries (>10 cm). 1
• Presence of suitable autogenous saphenous vein. 1, 2
• Acceptable surgical risk profile. 1, 2
• Diffuse multilevel disease requiring treatment at multiple anatomic levels. 1
• Single-vessel runoff distal to ankle. 1

Endovascular Revascularization Options

Plain Balloon Angioplasty (POBA)

• POBA can be used as first choice for stenotic lesions and short occlusions. 1
• POBA has lower 12-month primary patency compared to drug-coated balloons (RR 0.50,95% CI 0.27-0.93) and atherectomy + DCB (RR 0.34,95% CI 0.12-0.93). 3
• POBA has higher 12-month target lesion revascularization (TLR) rates than DCB (RR 1.76,95% CI 1.07-2.90). 3

Drug-Coated Balloons (DCB)

• DCB shows better patency than bare-metal stents in infrapopliteal arteries. 2
• DCB had lower 6-month TLR rates compared to absorbable metal stents (RR 0.26,95% CI 0.08-0.86) and POBA (RR 0.51,95% CI 0.30-0.89). 3

Drug-Eluting Stents (DES)

• DES are recommended over bare-metal stents for infrapopliteal intervention due to superior patency rates. 2
• DES decreased 6-month TLR compared to bare-metal stents (RR 0.25,95% CI 0.09-0.71). 3
• Stenting provides superior 3-year amputation-free survival compared to POBA (78.1% vs 69.5%, HR 0.73,95% CI 0.60-0.90). 4
• The interval to target extremity reintervention is nearly double for stenting compared to POBA or atherectomy (12.8 months vs 7.7 months). 4

Atherectomy Devices

• Atherectomy combined with balloon angioplasty (AD + BA) ranks highest for 6-month TLR (SUCRA = 83.1), 12-month TLR (SUCRA = 75.8), and 12-month all-cause mortality (SUCRA = 92.5). 3
• Atherectomy combined with drug-coated balloon (AD + DCB) had the best primary patency at 6 months (SUCRA = 87.5) and 12 months (SUCRA = 91). 3
• However, AD + DCB had the worst 12-month major amputation rate (SUCRA = 28.8). 3
• AD + BA consistently ranks higher than AD + DCB across multiple outcomes. 3
• Technical success rates for atherectomy are similar to angioplasty (93% vs 85%). 5

When to Choose Endovascular Over Surgical

• Increased surgical risk due to comorbidities (coronary ischemia, cardiomyopathy, congestive heart failure, severe lung disease, chronic kidney disease). 1
• Absence of suitable autogenous vein conduit. 1, 2
• Stenotic lesions or short occlusions (<10 cm). 1, 2
• Patient preference for less invasive approach with acceptable short-term patency for wound healing. 1

Angiosome-Directed Therapy

• Angiosome-directed endovascular therapy may be reasonable for patients with CLTI and nonhealing wounds or gangrene (Class IIb). 1
• This approach establishes direct blood flow to the infrapopliteal artery directly perfusing the region with the nonhealing wound. 1
• Meta-analyses found improved wound healing and limb salvage with angiosome-guided therapy, but evidence quality is low. 1
• Important considerations include longer procedural times, more contrast exposure, and more technically complex procedures. 1

Critical Pitfalls to Avoid

• Never perform prophylactic revascularization for asymptomatic PAD or claudication to prevent CLI progression—procedural risks outweigh hypothetical benefits. 2
• Do not use bare-metal stents in infrapopliteal arteries due to high restenosis rates. 2
• When choosing an endovascular-first approach, preserve landing zones for potential bypass grafts. 1
• Avoid treating infrapopliteal disease without addressing concurrent inflow disease (aorto-iliac or femoro-popliteal lesions), as up to 40% of CLTI cases require inflow treatment. 1
• Do not rely solely on revascularization without addressing cardiovascular risk factors, as mortality in PAD is primarily from cardiovascular events, not limb-related complications. 2

Adjunctive Management Requirements

• Optimal glycemic control is recommended in patients with CLTI and diabetes (Class I, Level C). 1
• Initiate antiplatelet therapy immediately and continue indefinitely (Class I, Level A) after revascularization, unless contraindicated. 2
• Angiography including foot runoff should be considered prior to revascularization in CLTI patients with below-the-knee lesions (Class IIa, Level B). 1
• Revascularization is needed before minor amputation to improve wound healing. 1

Special Considerations

• Stem cell and gene therapy are not indicated for CLTI (Class III, Level B). 1
• Primary major amputation should be considered for patients with extensive necrosis, infectious gangrene, non-ambulatory status with severe comorbidities, or when revascularization has failed and re-intervention is no longer possible. 1