An 80‑year‑old woman with Doppler evidence of an occluded left superficial femoral artery and high‑resistance waveforms should be referred to which specialty for definitive management?

Referral to Vascular Surgery

This 80-year-old patient with an occluded left superficial femoral artery and high-resistance waveforms requires referral to vascular surgery. 1, 2

Rationale for Vascular Surgery Referral

Vascular surgeons are the primary specialists who manage peripheral arterial disease involving the superficial femoral artery, with particular expertise in both endovascular and open surgical revascularization techniques. 2 The ACC/AHA guidelines specifically designate vascular surgery as the appropriate specialty for managing lower extremity peripheral arterial disease, including SFA occlusions. 3

Why Vascular Surgery Over Other Specialties

• Vascular surgeons provide comprehensive management of both acute and chronic lower extremity arterial occlusive disease, including medical optimization, endovascular intervention, and open surgical bypass when indicated. 1, 2
• Interventional radiologists and interventional cardiologists serve as alternative specialists primarily for endovascular approaches, but vascular surgery remains the primary referral for comprehensive PAD management. 2
• The Society for Vascular Surgery guidelines specifically address management of femoropopliteal disease, making this the most appropriate specialty. 2

Critical Clinical Assessment Required

Before or at the time of vascular surgery consultation, the following must be determined:

Symptom Severity Classification

• Critical limb ischemia (CLI) — defined by rest pain, non-healing ulceration, or gangrene — requires semi-urgent vascular surgery consultation and revascularization within days-to-weeks. 1
• Lifestyle-limiting claudication warrants initial medical therapy and supervised exercise for at least 3 months before considering revascularization. 3, 1
• Asymptomatic disease is managed with medical therapy alone without revascularization. 1

Physical Examination Findings to Document

• Examine bilateral femoral, popliteal, dorsalis pedis, and posterior tibial pulses; assess for dependent rubor, elevation pallor, cool skin, and non-healing wounds. 1
• Auscultate for femoral bruits, which suggest proximal arterial stenosis. 1
• High-resistance waveforms on Doppler indicate severely compromised distal flow and suggest either complete occlusion or severe stenosis with poor runoff. 3, 1

Disease-Specific Considerations for This Patient

Anatomic and Prognostic Implications

• Left SFA occlusion is the most common cause of intermittent claudication, typically producing calf discomfort during ambulation. 1
• Complete SFA occlusion is classified as TASC type D femoropopliteal disease, for which surgical bypass is the preferred treatment due to superior long-term patency compared to endovascular therapy. 1
• The combination of complete SFA occlusion with severe distal tibial disease (suggested by high-resistance waveforms) markedly increases the risk of progressing to critical limb ischemia. 1

Age-Related Risk Factors

• Age ≥80 years is associated with reduced 2-year survival after revascularization. 3, 1
• Additional high-risk comorbidities (BMI <18 kg/m², non-ambulatory status, hemodialysis dependence, cerebrovascular disease, LVEF <40%) further worsen prognosis and must be assessed. 3, 1

Mandatory Medical Therapy (Initiated Immediately)

Regardless of symptom severity or revascularization plans, all PAD patients require:

• Antiplatelet therapy (aspirin or clopidogrel). 1
• High-intensity statin therapy irrespective of baseline cholesterol levels. 1
• Aggressive cardiovascular risk-factor modification (smoking cessation, diabetes control, hypertension management). 1
• Cilostazol in patients with claudication to improve walking distance (minimum 3 months trial). 3, 1

Timing of Referral

• Immediate referral (within 24-48 hours) is warranted if the patient develops rest pain, tissue loss, sudden worsening of symptoms, loss of pulses, or any signs of acute ischemia. 1
• Routine referral is appropriate for stable claudication symptoms, with the understanding that medical therapy and supervised exercise should be optimized first. 1
• Semi-urgent referral (within days-to-weeks) is required if CLI is present. 1

Common Pitfalls to Avoid

• Do not assume symptoms are benign claudication without thorough assessment; complete SFA occlusion plus severe distal disease (high-resistance waveforms) raises the risk of progressing to CLI. 1
• Do not delay revascularization when CLI is present; untreated CLI leads to major amputation within 6 months and 25-35% one-year mortality. 1
• Recognize that documented PAD markedly elevates cardiovascular mortality; aggressive risk-factor modification is essential even if limb symptoms are mild. 1
• In patients aged ≥80 years, carefully weigh surgical risk against potential benefit, as age alone increases peri-operative complication risk. 1