What is the recommended treatment regimen for patients with Peripheral Vascular Disease (PVD) undergoing endovascular therapy?

Endovascular Therapy for Peripheral Vascular Disease

Direct Recommendation

Endovascular intervention is the first-line revascularization approach for most patients with symptomatic PAD, particularly for TASC A and B lesions in both aorto-iliac and femoropopliteal territories, with treatment decisions guided by anatomic complexity, clinical presentation severity, and patient surgical risk. 1

Treatment Algorithm by Anatomic Location

Aorto-Iliac Disease

Primary stenting is the preferred endovascular approach for common iliac artery stenoses and occlusions (TASC A/B lesions), while balloon angioplasty with selective stenting is appropriate for external iliac arteries. 1

• For common iliac artery lesions, proceed directly to primary stenting as it achieves superior long-term patency compared to angioplasty alone 1
• For external iliac artery lesions, perform balloon angioplasty first, reserving stents for suboptimal results (persistent gradient, >50% residual stenosis, or flow-limiting dissection) 1
• Measure translesional pressure gradients (with and without vasodilation) for angiographic stenoses of 50-75% diameter before proceeding with intervention 1
• Short-term morbidity and mortality favor endovascular approaches over open surgery, though mid-term primary patency favors surgery; however, secondary patency rates are comparable 1

Femoropopliteal Disease

Endovascular therapy should be the first-choice revascularization strategy for femoropopliteal lesions, even for complex anatomy, particularly in high surgical risk patients. 1

• Drug-eluting balloons are safe and effective for improving long-term patency in femoropopliteal lesions after initial FDA safety concerns were not confirmed in large database analyses 1
• Primary stenting in the femoral or popliteal arteries is NOT recommended; stents should be reserved as salvage therapy for failed angioplasty (persistent gradient, >50% residual stenosis, flow-limiting dissection) 1
• Consider open surgical bypass with autologous vein (great saphenous vein) when available in low surgical risk patients with complex lesions after interdisciplinary team discussion 1

Below-the-Knee (Infrapopliteal) Disease

In patients with severe claudication undergoing femoropopliteal intervention, treat below-the-knee arteries in the same session only if there is substantially impaired outflow. 1

• Primary stenting, atherectomy, cutting balloons, and laser therapy are NOT well-established for infrapopliteal lesions except as salvage for failed angioplasty 1
• For critical limb ischemia, endovascular procedures are recommended to establish in-line blood flow to the foot 1

Clinical Presentation-Based Approach

Intermittent Claudication

Endovascular intervention is indicated only after 3 months of optimal medical therapy (OMT) and supervised exercise therapy have failed, AND the patient has lifestyle-limiting disability with favorable anatomic features. 1

• Do NOT perform prophylactic endovascular intervention in asymptomatic patients 1
• Endovascular therapy is NOT indicated to prevent progression to limb-threatening ischemia 1
• TASC A lesions are ideal for endovascular-first approach 1
• TASC D lesions favor surgical revascularization 1

Critical Limb-Threatening Ischemia (CLTI)

For patients with CLTI and life expectancy >2 years with available autogenous vein, surgical bypass is reasonable as initial treatment; for life expectancy ≤2 years or no suitable vein, endovascular therapy is reasonable as the initial approach. 1

• Endovascular procedures establish in-line blood flow with comparable amputation-free survival to surgery 1
• For combined inflow and outflow disease, address inflow lesions first; if CLI symptoms persist, then perform outflow revascularization 1
• A staged endovascular approach is reasonable for patients with ischemic rest pain 1

Post-Procedural Antithrombotic Management

Standard Risk Patients (No High-Risk Features)

Single antiplatelet therapy with aspirin or clopidogrel is recommended for patients without high-risk limb presentation or comorbidities. 1

High-Risk Patients (No Anticoagulation Required)

Aspirin plus rivaroxaban 2.5 mg twice daily is reasonable for patients with high-risk limb presentation (previous amputation, CLTI, prior revascularization) or high-risk comorbidities (heart failure, diabetes, multivessel disease, eGFR <60 mL/min/1.73 m²) without high bleeding risk. 1

Immediately Post-Endovascular Revascularization

Dual antiplatelet therapy (DAPT) for 1-3 months followed by single antiplatelet therapy is reasonable after endovascular revascularization in patients without anticoagulation requirements. 1

• For patients requiring long-term anticoagulation without high bleeding risk, combine single antiplatelet therapy for 1-3 months with oral anticoagulation 1
• For patients with high bleeding risk (dialysis, GFR <15, recent ACS <30 days, history of intracranial hemorrhage), use oral anticoagulation monotherapy 1

Critical Contraindications

Do NOT perform endovascular intervention if there is no significant pressure gradient across a stenosis despite vasodilator administration. 1

Common Pitfalls to Avoid

• Avoid primary stenting in femoropopliteal and tibial arteries—this is associated with worse outcomes in highly mobile arterial segments and should be reserved for salvage only 1
• Do not delay treatment in CLTI patients; these require urgent evaluation and revascularization within days, not weeks 1
• Do not assume younger age (<50 years) benefits from aggressive surgical intervention—these patients often have more virulent atherosclerosis with poorer long-term outcomes 1
• Avoid treating asymptomatic PAD with revascularization—there is no evidence this prevents progression to limb-threatening ischemia 1