What is the preferred revascularization strategy, endovascular or bypass, for a patient with Peripheral Vascular Disease (PVD) requiring intervention?

Revascularization Strategy for Peripheral Vascular Disease: Endovascular vs Bypass

For chronic limb-threatening ischemia (CLTI) with available autogenous saphenous vein and acceptable surgical risk, bypass surgery is the preferred initial revascularization strategy, while endovascular intervention is recommended for claudication, short lesions, high-risk surgical candidates, or absence of suitable vein conduit. 1

Clinical Presentation Determines Strategy

For Claudication

• An endovascular-first approach is recommended for symptomatic claudication requiring revascularization after failed medical therapy 1
• Endovascular intervention is particularly appropriate for:
  • Short aortoiliac lesions (<5 cm) 1
  • Short femoropopliteal lesions (<25 cm) 1
  • Patients with lifestyle-limiting symptoms despite optimal medical therapy 1
• Surgical revascularization should not be performed solely to prevent progression to CLTI, as progression occurs in only 10-15% of patients over 5 years 1, 2, 3

For Chronic Limb-Threatening Ischemia (CLTI)

The 2024 ACC/AHA guidelines and BEST-CLI trial have fundamentally informed this decision:

Bypass surgery is preferred when:

• Autogenous saphenous vein is available 1
• Patient has acceptable perioperative risk 1
• Life expectancy exceeds 2 years 1
• Long segment disease (>25 cm in femoropopliteal territory) 1
• Multilevel chronic total occlusions 1
• Lesions involving both common femoral artery and profunda femoris origin 1

Endovascular intervention is preferred when:

• High estimated perioperative risk (severe coronary disease, heart failure, advanced lung disease, frailty) 1
• No suitable autogenous vein conduit available 1
• Short stenotic lesions or occlusions 1
• Patient preference after shared decision-making 1

Anatomic Segment-Specific Recommendations

Aortoiliac Disease

• Endovascular approach is first-line for most aortoiliac lesions 1
• Surgery reserved for extensive obstructions or failed endovascular procedures 1
• Hybrid revascularization appropriate for common femoral artery disease requiring endarterectomy plus inflow/outflow disease 1

Femoropopliteal Disease

• Endovascular-first for lesions <25 cm 1
• Bypass surgery with autogenous saphenous vein for lesions ≥25 cm when vein available and life expectancy >2 years 1
• The autogenous saphenous vein is mandatory as conduit of choice—prosthetic grafts have inferior outcomes 1

Infrapopliteal Disease

• Bypass with autogenous saphenous vein is the gold standard for CLTI 1, 2
• Endovascular therapy reasonable for short stenoses or occlusions, or when surgical risk is prohibitive 1, 2
• Revascularization for isolated infrapopliteal claudication has uncertain benefit and is not routinely recommended 2

Critical Evidence from Recent Trials

The BEST-CLI trial (2024) demonstrated comparable amputation rates between endovascular and surgical approaches, but with important nuances 1:

• Patients with adequate saphenous vein had better outcomes with bypass surgery
• Endovascular outcomes were comparable to surgery in patients without suitable vein conduit

The BASIL-2 trial showed superior outcomes with endovascular intervention over bypass for infrapopliteal CLTI 1, though this must be balanced against the longer-term durability advantages of vein bypass 1

Essential Technical Considerations

Bypass Surgery Requirements

• Ipsilateral greater saphenous vein is the preferred conduit; if unavailable, use contralateral leg or arm vein 1, 2
• Bypass should be as short as possible to maximize patency 1
• Prosthetic grafts to tibial arteries should never be used for claudication (Class III: Harm) 1

Endovascular Approach

• Preserve landing zones for potential future bypass grafts 1, 2
• Drug-eluting stents superior to bare-metal stents in infrapopliteal arteries 2
• Establish in-line blood flow to at least one foot artery 1, 4

Common Pitfalls to Avoid

• Never perform prophylactic revascularization in asymptomatic PAD, regardless of anatomic severity 3
• Do not revascularize claudication patients solely to prevent CLTI progression—mortality in PAD is primarily from cardiovascular events, not limb complications 2, 3
• Always evaluate revascularization options via multidisciplinary team before amputation in CLTI 1
• Do not proceed with revascularization in nonviable limbs with extensive necrosis beyond salvage potential 1, 3
• Ensure 3-month trial of optimal medical therapy and supervised exercise before revascularization for claudication 3

Hybrid Revascularization

Hybrid procedures combining endovascular and open techniques are appropriate for:

• Common femoral artery disease requiring endarterectomy plus proximal/distal disease 1
• Complex multilevel disease 1
• Similar patency and limb salvage rates to open reconstruction when properly selected 1