eMedicine Specialties > Vascular Surgery > Medical Topics
Infrainguinal Occlusive Disease: Treatment
Updated: Jun 24, 2008
Treatment
Medical Therapy
Most patients with atherosclerotic lower extremity disease do not undergo surgical treatment. In fact, only 25% of patients presenting with intermittent claudication eventually require invasive treatment of limb-threatening ischemia or intractable symptoms, and only 5-10% do so within 5 years of the onset of claudication.
The cornerstones of medical management of intermittent claudication are walking and elimination or control of medical risk factors.27,28 For further reading, see the eMedicine articles Atherosclerosis and Coronary Artery Atherosclerosis.
Walking
Encourage walking.29 Regular walking of approximately 1 hour per day usually results in a significant increase in walking distance over time. This increase in walking distance has been noted to range from 80% to more than 200%. Improvement results from improved flow in collateral pathways.
Risk factor management
- Discontinue cigarette smoking. A major factor contributing to progressive and intractable atherosclerotic disease is cigarette smoking. One study noted an 85% chance of improvement if smoking is stopped versus only a 20% chance of improvement if the patient continues smoking.
- Control medical risk factors. Other risk factors that must be assessed and controlled are obesity, hypertension, hyperlipidemia, and diabetes.30
- Ensure meticulous foot care. Because an ischemic foot is at risk for developing limb-threatening ulceration from even minor trauma, good foot hygiene and appropriately fitting shoes are important. This is even more vital for patients with diabetes, who are also at risk for neuropathic foot ulcers.
Pharmacotherapy
- Discuss pharmacotherapy. Currently available drugs that may benefit patients with mild or moderate claudication include pentoxifylline and cilostazol.31,32 Controlled studies suggest that each of these drugs improves walking distance by approximately 20% more than placebo, cilostazol perhaps slightly more than pentoxifylline.
- Cilostazol (Pletal), administered at 100 mg orally twice daily, has demonstrated some benefit for claudication symptoms.33 Cilostazol is contraindicated in patients with congestive heart failure.34 The product's black box warning reads as follows:
Cilostazol and several of its metabolites are inhibitors of phosphodiesterase III. Several drugs with this pharmacologic effect have caused decreased survival compared to placebo in patients with class III-IV congestive heart failure. Pletal is contraindicated in patients with congestive heart failure of any severity.
- Pentoxifylline (Trental), 400 mg orally 3 times per day taken with meals, has been available for many years. After 2-3 months of use, 25-60% of patients demonstrate some improvement in walking distance. However, much of this improvement may be attributable to exercise and to modification of the risk factors mentioned above. The major adverse effects of this medication are gastrointestinal in nature.
- Antiplatelet agents (eg, aspirin, clopidogrel), angiotensin-converting enzyme inhibitors, and statins should also be considered.
Surgical Therapy
Surgical or endovascular intervention is indicated for intractable and disabling claudication, for ischemic pain at rest, and for ischemic necrosis (see Image 1). Surgery also may be useful for nonhealing ischemic ulceration.
Before considering surgical intervention, the clinician must address the possibility of coexisting atherosclerotic heart and cerebrovascular disease, which are extremely common in patients with atherosclerotic peripheral arterial disease. One study found that only 14% of patients with peripheral arterial disease had normal coronary arteries, while 15% had severe coronary artery disease that required surgical correction. See the eMedicine article Atherosclerosis for the cardiologic workup.
Obtain appropriate imaging studies. Before surgical intervention, the exact extent of the atherosclerotic disease is mapped using high-quality contrast angiography (see Imaging Studies).
Preoperative Details
Prior to vascular surgery, a routine laboratory workup is performed, including complete blood cell count, biochemical profile, clotting studies, urinalysis, chest radiography, and ECG. Abnormalities are addressed.
Radiographic contrast
If an endovascular procedure is to be performed, iodinated contrast material is required, and hence, one must check for renal insufficiency, a history of contrast allergy, and the use of metformin (Glucophage; see Imaging Studies).
Infection prevention
Take appropriate measures to prevent vascular graft infection:
- For routine prophylaxis in bypass surgery, a broad-spectrum antibiotic, such as a broad-spectrum cephalosporin, a penicillin/β-lactamase inhibitor, or an aminoglycoside, is administered just before surgery and postoperatively for 1 to 3 doses.
- If there is known colonization with or local prevalence of methicillin-resistant staphylococcus aureus (MRSA), consider vancomycin or teicoplanin.35
- Consider a preoperative antiseptic shower or scrub.
- Patients harboring a potential infection (eg, foot ulcer, gangrene) may fare better having the infected tissue excised, even with limited amputations, prior to vascular intervention in order to avoid graft or wound infections.
Urgent intervention
If urgent intervention is required, the workup may have to be truncated. In the case of acute arterial occlusion, the workup may have to be minimal because prompt thrombectomy is often required for limb salvage. Preoperative angiography may still be warranted, especially if evidence of underlying atherosclerotic disease is present.
Intraoperative Details
Although peripheral arterial disease is a diffuse process, often the preponderance of findings can be attributed to a particular segment of the arterial tree. Angiographic findings combined with knowledge of the patient's symptoms, physical findings, and noninvasive laboratory results leads the vascular specialist to determine which artery or arteries are best treated by invasive means.36 This determination is not an exact science, and it is not unusual for the vascular specialist to correct a single lesion and then discover that the recurring symptoms dictate another procedure at a later date. Nonetheless, attempting to correct all diseased segments at once usually confers too high an operative risk.
Disease of the iliac artery
Hemodynamically significant disease involving the iliac arteries, particularly short-segment stenotic and even occlusive disease, can usually be successfully treated using percutaneous angioplasty, percutaneous insertion of an arterial stent, or both.
If endovascular reconstruction is not possible, femorofemoral crossover bypass is usually the best choice for unilateral iliac artery occlusion and aortobifemoral bypass is usually the best choice for bilateral or diffuse aortoiliac disease.
Axillofemoral bypass is an alternative in high-risk patients who cannot tolerate an intra-abdominal or retroperitoneal operation (see the eMedicine article Aortoiliac Occlusive Disease).
Disease involving the femoral artery
Hemodynamically significant disease involving the femoral artery is usually the result of relatively long-segment occlusion of the distal superficial femoral artery in the adductor canal.
Endovascular approaches to infrainguinal disease have become increasingly successful. Secondary interventions are often required, but assisted patency rates are reported as over 90% in appropriately selected patients.
Correction of this type of disease often requires bypass from a pulsatile distal common femoral artery to the pulseless popliteal artery. Such a bypass is best performed using the ipsilateral greater saphenous vein. If this vein is not suitable (or has been used previously), alternative conduits for above-knee bypasses include expanded polytetrafluoroethylene prosthetic graft (Gore-Tex, Impra), Dacron, tanned bovine umbilical vein graft, and glutaraldehyde tanned human human umbilical vein.37
Because of inferior patency rates with prosthetic grafts extending below the knee, the vascular surgeon usually tries to locate a usable autologous vein from the contralateral lower extremity by combining available short segments from both sides, upper extremity veins, or even composite grafts (in which a prosthetic graft extends to the knee and a piece of autologous vein is attached distally or when a vein patch is used to attach the prosthetic graft to the distal artery).
Angioplasty with or without stenting may be appropriate for short-segment superficial femoral artery occlusive disease.
Disease involving the infrapopliteal arterial tree
Extensive disease involving the infrapopliteal segments is best managed by autologous vein grafting. Arguably, the best technique is the use of the ipsilateral saphenous vein in situ.
This is a somewhat tedious procedure in which the saphenous vein is first disconnected from the femoral vein in the groin and anastomosed to the common femoral artery. The vein is then transected distally, and a valvulotome is inserted retrograde and withdrawn in order to destroy the valves that would have prevented arterial flow from the groin to the leg in the vein. Next, an anastomosis is created between the distal end of the vein and a usable small artery, even as far distally as the dorsalis pedis at the ankle or foot. Finally, the vein branches are ligated to stop arteriovenous flow.
Patients must be selected carefully for this technique. The vein must be patent and of adequate length and caliber, and a usable, soft distal artery must be available. Preoperative vein mapping using duplex scanning is sometimes helpful.
Endovascular procedures
Percutaneous transluminal angioplasty is often appropriate for strictures or short-segment occlusions of the superficial femoral, popliteal, and, occasionally, infrapopliteal arteries.38,4,39 Angioplasty is performed by passing a guidewire through the lumen of the strictured artery and then advancing a balloon angioplasty catheter over the guidewire. The balloon is inflated to several atmospheres of pressure under angiographic visualization. This effectively disrupts the plaque and provides a wider, patent lumen.
Although angioplasty has been used increasingly for claudication, whether the risks justify the benefits for many patients in this group is a serious question.40
Somewhat surprisingly, even if the guidewire cannot negotiate the lumen of a stricture and instead passes through the subintimal plane, subintimal (extraluminal) angioplasty may succeed.41 This method seems to create a new channel in a virgin plane. Low echogenicity at the distal end of the plaque, as measured by duplex ultrasound–derived gray-scale median, seems to increase the chance of successful subintimal angoplasy.42
Angioplasty may be combined with percutaneous stenting. Self-expanding nickel-titanium alloy (nitinol) stents have demonstrated a 2-year primary patency rate of 47% and a limb salvage rate of 66% when used to treat limb ischemia.43
In addition to intra-procedure anticoagulation, patients are typically treated with an antiplatelet agent, such as clopidogrel, both before and for a month or more postprocedure.43
Percutaneous endovascular removal of atherosclerotic plaque (ie, atherectomy) seemed quite promising in the early 1990s, but it was abandoned because of very poor long-term success rates. More recently, however, it has garnered some renewed interest in research settings.44,45,46,47
Endarterectomy
Removal of atherosclerotic plaque and underlying diseased arterial intima (endarterectomy) at anastomotic sites is sometimes necessary as an adjunct to bypass surgery but is indicated only rarely as the sole management for lower extremity arterial occlusive disease.
One exception is endarterectomy of the deep femoral artery (profundoplasty), which may be useful in the rare case of severe limb-threatening stenosis of the origin of the deep femoral artery associated with a superficial femoral artery occlusion that cannot be bypassed for technical reasons.
Another indication for endarterectomy is to remove localized embolizing ulcerated plaque.
Management of acute arterial occlusion
The usual immediate management of acute arterial occlusion is immediate heparin anticoagulation and rapid surgical thromboembolectomy. If time allows, especially if atherosclerotic thrombosis is suggested, preoperative angiography is often wise. It may provide information vital to performing bypass surgery should thrombectomy disclose severe underlying atherosclerotic disease. In some cases, particularly very high-risk patients, thrombolytic therapy by selective intra-arterial infusion (if available) is a reasonable alternative to emergency surgery. For infrainguinal acute occlusions, a medial approach to the distal popliteal artery trifurcation is usually the best method to allow complete evaluation and clearance of all outflow vessels.
After relief of an acute arterial occlusion, one must be alert to the possibility of reperfusion complications such as compartment syndrome or myopathic-metabolic-nephrotic syndrome. Compartment syndrome is characterized by tense edema of the leg, which raises interstitial tissue pressures and impedes arterial inflow. Emergency 4-compartment fasciotomy can save limbs. Myopathic-metabolic-nephrotic syndrome is the result of reperfusion of essentially irreversibly ischemic muscle. It is characterized by metabolic acidosis, dark urine, and renal failure. Emergency limb amputation may be required to save the patient's life.
After emergent treatment to salvage the ischemic limb, the clinician must determine the etiology of the acute occlusion. If it was thrombotic, the underlying atherosclerotic disease may require correction. If it was embolic, the source must be sought. Ninety percent of arterial emboli originate in the heart. The remaining emboli originate in the aorta (see Differential diagnoses) or from venous thrombi that pass into the arterial circulation via a right-to-left intracardiac shunt (paradoxical embolism). Sometimes, the source can be treated, but usually, long-term anticoagulation is required.
Aneurysm resection is indicated for symptomatic, expanding, or sizable popliteal artery aneurysms. A vein graft is usually used to replace the resected or excluded popliteal artery segment. Management of aortic aneurysms is covered in the eMedicine article Thoracic Aortic Aneurysm.
Postoperative Details
Postoperative care after vascular surgery requires in-hospital observation in order to expeditiously detect and treat complications.
Occlusion
The most frequent complication of endovascular and vascular surgical procedures is occlusion. Some authorities recommend the use of antiplatelet therapy (eg, aspirin or clopidogrel) starting before angioplasty or bypass surgery and continuing indefinitely. For grafts considered to be at high risk for thrombosis, such as those with poor runoff, with a previous occlusion, with a prosthetic graft, or in a hypercoagulable state, heparin may be given perioperatively, and warfarin may be administered for long-term prophylaxis.
Acute postoperative thrombosis
Any change in circulatory status beyond the bypass graft warrants a rapid evaluation. If thrombosis has occurred, rapid return to the operating room for thrombectomy and repair is required. In such cases, a technical problem (eg, intimal flap) must be sought.
Normal postoperative recovery
Ambulation with the assistance of a physical therapist usually starts gradually on the first or second postoperative day. The timing of hospital discharge varies with the extent of the procedure and the patient's general condition. If bypass surgery has been performed in conjunction with significant distal amputations, recovery in a skilled nursing facility or rehabilitation center may be beneficial.
Management following percutaneous procedures
Following percutaneous procedures, the patient is observed from 4 hours to overnight to ensure absolute bed rest and detect possible complications of the puncture and intervention. Antiplatelet therapy is usually prescribed. For patients with renal compromise and those on metformin, check serum creatinine values 1-2 days after the procedure.
Follow-up
A routine postoperative follow-up assessment is essential for 2 reasons. First, medical management of the underlying atherosclerotic disease must continue. Second, bypass graft surveillance using noninvasive vascular laboratory testing may help detect problems that can threaten graft patency. Such problems include progressive atherosclerotic disease of inflow or outflow vessels or buildup of scar tissue (neointimal fibrous hyperplasia) at the anastomotic sites. If these problems can be detected before they lead to graft thrombosis, they may be corrected using endovascular means (ie, angioplasty, stenting). Open surgical revision for restenosis of vein grafts, however, carries a higher long-term success rate than percutaneous intervention.48
A typical schedule for outpatient follow-up after peripheral arterial intervention is at 2 weeks, 1 month, 3 months, 6 months, and every 6 months thereafter.
Complications
Important complications of vascular surgery include early postoperative occlusion, hemorrhagic problems, graft infection, cardiac morbidity, and restenosis.
Early postoperative occlusion
Early postoperative arterial or graft occlusion usually occurs as a result of technical factors such as an intimal flap or the use of a suboptimal conduit.49 Early reocclusion warrants a quick return to the operating room for thrombectomy and repair of any potential technical defect.
Unfortunately, the long-term prognosis after a take-back procedure for early graft occlusion is poor, with only approximately one quarter of such grafts still functional 5 years later.
Hemorrhagic problems
Hemorrhage and pseudoaneurysm formation may occur at the arterial puncture site or, less commonly, at a graft suture line. Management of the latter usually requires a return to the operating room for surgical repair; however, endovascular puncture site pseudoaneurysms can sometimes be treated using ultrasound-guided compression repair.50 In this technique, guided by continuous duplex scanning, the pseudoaneurysm is compressed just enough to stop flow outside the lumen of the involved artery but still preserve distal arterial flow. This compression continues for approximately 45 minutes, until the pseudoaneurysm thromboses. Arteriovenous fistulas have also been treated using this technique. More recently, ultrasound guided percutaneous thrombin injection has been shown to be quite effective and more expeditious.51
Graft infection
Prosthetic graft infections are rare but serious and may require removal of the bypass graft and even amputation of the limb. They occur in approximately 1% of prosthetic graft bypasses. Currently, methicillin-resistant Staphylococcus aureus is the preponderant pathogen.
Treatment usually requires complete removal of the graft and, if possible, reconstruction using a new graft via an extra-anatomic pathway, such as an iliac-popliteal bypass from the iliac artery via the obturator foramen to the popliteal artery beyond the infected graft's distal anastomosis.
Cardiac morbidity
Plaque in the superficial femoral artery (SFA) tends to be a late development in patients with generalized atherosclerotic disease. Therefore, the presence of SFA plaque conveys a very high likelihood of coexisting cardiac or carotid atherosclerosis.52
Because of this association of atherosclerotic coronary artery disease with peripheral arterial disease, postoperative myocardial events such as cardiac death, nonfatal myocardial infarction, unstable angina, ventricular tachycardia, and congestive heart failure may occur following infrainguinal bypass operations.
Although most studies suggest an overall cardiac complication rate of approximately 5%, one study found that such myocardial events occurred at an alarming rate of 24% in 87 patients undergoing infrainguinal reconstruction.
Restenosis
The most common late complication of both endovascular and vascular reconstructive procedures is restenosis resulting from a proliferation of smooth muscle cells causing an excessively thickened neointima, which can lead to late arterial or graft reocclusion. This is best prevented by routine postoperative graft surveillance and managed by endovascular repair, patch grafting, of bypass revision before occlusion occurs (see Follow-up care).
More on Infrainguinal Occlusive Disease |
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| Workup: Infrainguinal Occlusive Disease |
 Treatment: Infrainguinal Occlusive Disease |
| Follow-up: Infrainguinal Occlusive Disease |
| Multimedia: Infrainguinal Occlusive Disease |
| References |
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Further Reading
Keywords
infrainguinal occlusive disease, peripheral atherosclerotic disease, peripheral vascular disease, chronic arterial insufficiency, femoropopliteal occlusive disease, aortoiliac occlusive disease, stent, stenting, ischemic lower extremity disease, arteriosclerosis obliterans, complex regional pain syndromes, CRPS, posttraumatic pain syndromes, causalgia, mimocausalgia, Sudeck atrophy, reflex sympathetic dystrophy, intermittent claudication, gangrene, amputation
