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The natural history of peripheral vascular disease. Implications for its management
1Department of Vascular Surgery, Cleveland Clinic Foundation, Ohio 44195-5272.
Insights
Endovascular therapy for femoropopliteal atherosclerotic lesions lacks established indications due to unclear long-term outcomes. Current evidence suggests conservative management for claudication, prioritizing limb salvage and coronary artery disease assessment.
Area of Science:
- Vascular Surgery
- Interventional Cardiology
- Peripheral Artery Disease
Background:
- Endovascular therapies like angioplasty and atherectomy are increasingly used for femoropopliteal atherosclerotic lesions.
- The long-term durability and complication rates of these endovascular interventions remain incompletely defined.
- Established indications for endovascular therapy are lacking, necessitating careful consideration of the disease's natural history.
Purpose of the Study:
- To evaluate the current understanding of endovascular therapy for femoropopliteal arterial disease.
- To discuss the appropriate indications for endovascular interventions versus conservative management.
- To highlight the importance of assessing comorbidities, particularly coronary artery disease, in patients with lower extremity ischemia.
Main Methods:
- Review of existing literature on endovascular therapy for femoropopliteal occlusive disease.
- Analysis of complication rates and durability of percutaneous transluminal angioplasty, laser-assisted angioplasty, and atherectomy.
- Comparison of outcomes between endovascular therapy, exercise programs, and surgical interventions.
Main Results:
- Intermittent claudication is the primary symptom in ~70% of patients with aortoiliac or femoropopliteal disease.
- Nondiabetic patients often improve with exercise, having low risks of deterioration (20-25%) or amputation (<10%).
- 5-year mortality for claudicants is 20-40%, with significant coronary artery disease found in up to 40%.
Conclusions:
- Endovascular therapy indications should mirror traditional surgical criteria (disabling claudication, limb salvage) until proven effective.
- Conservative management with exercise is effective for many patients with intermittent claudication.
- Thorough evaluation for coronary artery disease is crucial in patients with lower extremity ischemia undergoing intervention.
Abstract:
The durability and the eventual complication rate of endovascular therapy (percutaneous transluminal angioplasty, laser-assisted angioplasty, and atherectomy) are not yet entirely clear, especially with respect to the treatment of atherosclerotic lesions in the femoropopliteal or distal arterial segments. Therefore, the indications for its use have not been firmly established and must take into consideration the natural history of the occlusive disease itself. Although some type of procedural intervention clearly is warranted in the presence of ischemic rest pain or tissue necrosis, intermittent claudication is the only complaint in approximately 70% of patients who present with either aortoiliac or femoropopliteal involvement. Most nondiabetic patients experience substantial symptomatic improvement with a daily exercise program, and their long-term risks for either abrupt deterioration (20-25%) or amputation (less than 10%) are relatively low. In comparison, the 5-year mortality rate ranges from 20-40% even in claudicants, and as many as 40% of those with clinical indications of associated coronary artery disease have been shown angiographically to be candidates for myocardial revascularization. These observations suggest that traditional indications for surgical treatment (truly disabling claudication and/or limb salvage) also should be applied to endovascular therapy until its success is confirmed beyond speculation, and that incidental coronary disease deserves particular attention in patients with lower extremity ischemia.