Endovascular Therapies for Peripheral Arterial Disease

Abstract

Abstract-Peripheral arterial disease is one manifestation of systemic atherosclerosis. The prevalence of peripheral arterial disease increases with the age of the population. It is important to remember the significant association of coincident coronary artery disease, which is the major cause of mortality in these patients. (Figure 1). 1,2 It is important to remember the significant association of coincident coronary artery disease and cerebrovascular disease in these patients, because it represents the major cause of major morbidity and mortality in the PAD population. 3 Remarkable technological advances in the past decade, along with patient preference, have shifted revascularization strategies from traditional open surgical approaches toward lower-morbidity percutaneous endovascular treatments. Catheter-based revascularization of the lower extremities was first performed by Charles Dotter 4 and advanced by Andreas Gruentzig, who employed then newly developed inflatable balloon catheters that could dilate vascular stenoses. 5 The availability of stents, more than any other advance, has fueled the growth of catheterbased procedures by improving the safety, durability, and predictability of percutaneous revascularization.Endovascular therapy offers several distinct advantages over open surgical revascularization for selected lesions. 6,7 It is performed with local anesthesia, which enables the treatment of patients who are at high risk for general anesthesia. The morbidity and mortality from catheter-based therapy is extremely low, especially compared with open surgical revascularization. After successful percutaneous revascularization, patients are ambulatory on the day of treatment, and unlike after vascular surgery, they can often return to normal activity within 24 to 48 hours of an uncomplicated procedure. Endovascular therapies generally do not preclude or alter subsequent surgery and may be repeated if necessary.Multiple specialties, including interventional cardiology, have contributed to the advancement of the field of peripheral vascular intervention over the past several decades. 8 The recognition of an unmet need for a trained cadre of clinicians to care for patients with PAD prompted the development of a core curriculum document (COCATS-11) 9 and a multispecialty societal competency statement. 10 The American Heart Association and American College of Cardiology have published guidelines and recommendations for the diagnosis and treatment of PAD. 2 Improved patient and physician awareness of PAD and the availability of high-quality noninvasive diagnostic imaging have increased the number of patients seeking treatment for PAD. Diagnostic Evaluation Noninvasive AssessmentThe initial assessment should include a physical examination, with the patient's shoes and socks removed, to look for signs of acute or chronic peripheral ischemia and distal embolization and to determine the status of the peripheral pulses. The abdomen is examined for evidence of an aortic aneurysm, and blood pressure should be meas...

Peripheral Artery Disease: Current Insight Into the Disease and Its Diagnosis and Management

“…Because the results of iliac stenting are good and the restenosis rate is low, stenting may be offered as first-line therapy in patients with iliac disease-related claudication that interferes with lifestyle (Table 5). 105,106 The CLEVER (Claudication: Exercise Vs. Endoluminal Revascularization) study, which was funded by the Heart, Lung, and Blood Institute of the National Institutes of Health, is a prospective, multicenter, randomized, controlled clinical trial evaluating the relative efficacy, safety, and health economic impact of 3 treatment strategies for people with aortoiliac disease and claudication. The treatment arms are: optimal medical care (claudication pharmacotherapy) 2 ; optimal medical care and supervised exercise 3 ; and optimal medical care and stent.…”

“…Although the specific methods of endovascular (angioplasty, stent, atherectomy) or surgical therapy are beyond the scope of this article, certain principles should be adhered to when caring for patients with claudication. 105,106,136 These are summarized in Table 6.…”

Association between health status and long‐term mortality after percutaneous revascularization of peripheral artery disease

“…Overall, most patients had mild to moderate lesion complexity, including primarily TASC A and B lesion grade mostly of the iliofemoral segments with 20.2% being chronic total occlusions. Since the ALEVE study began, the ability to treat more complex artery disease with an endovascular approach has improved with significant technical advances [24,25]. Future studies are needed to determine whether these endovascular advances might influence the proportion of responders or the association between health status improvements and long-term QOL.…”

Are flow-mediated vasodilatation and intima-media thickness of the brachial artery associated with restenosis after endovascular treatment of peripheral arterial occlusive disease?

“…Development of endovascular therapies during recent decades has enlarged the possible therapeutic strategies besides the traditional open surgical interventions [21]. Early results after angioplasty are superior to those for conservative treatment, but this is not proven for long-term results because of late restenosis in treated segments [22].…”