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      Drugs & Diseases > Vascular Surgery

      Infrainguinal Occlusive Disease Guidelines

      Updated: Nov 13, 2023
      • Author: Christian Ochoa, MD; Chief Editor: Vincent Lopez Rowe, MD, FACS  more...
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      Guidelines

      SVS Guidelines for Femoropoliteal Occlusive Disease

      In 2015, the Society for Vascular Surgery (SVS) issued practice guidelines for management of atherosclerotic disease of the lower extremities. [40]  Recommendations for interventions for femoropopliteal occlusive disease (FPOD) in intermittent claudication (IC) include the following:

      • Endovascular therapy (EVT) is preferred to open surgery for focal occlusive disease of the superficial femoral artery (SFA) that does not involve the origin at the femoral bifurcation (grade 1 recommendation; evidence level C).
      • Selective stenting is suggested for focal lesions (< 5 cm) in the SFA that have unsatisfactory technical results with balloon angioplasty (grade 2 recommendation; evidence level C).
      • Adjunctive use of self-expanding nitinol stents (with or without paclitaxel) is recommended for intermediate-length (5-15 cm) SFA lesions to improve the midterm patency of angioplasty (grade 1 recommendation; evidence level B).
      • Preoperative ultrasonographic vein mapping is suggested to establish the availability and quality of autogenous vein conduit in patients being considered for infrainguinal bypass to treat IC (grade 2 recommendation; evidence level C).
      • EVT is not recommended for isolated infrapopliteal disease in IC, because it is of unproven benefit and may be harmful (grade 1 recommendation; evidence level C).
      • Surgical bypass is recommended as an initial revascularization strategy for patients with diffuse FPOD, small vessel caliber (< 5 mm), or extensive SFA calcification if their anatomy is favorable for bypass (popliteal artery target, good runoff) and their operative risk is average or low (grade 1 recommendation; evidence level B).
      • The saphenous vein is the preferred conduit for infrainguinal bypass grafts (grade 1 recommendation; evidence level A).
      • In the absence of suitable vein, a prosthetic conduit is suggested for femoropopliteal bypass in claudicant patients if the above-knee popliteal artery is the target vessel and good runoff is present (grade 2 recommendation; evidence level C).
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      ESC/ESVS Guidelines for Infrainguinal Occlusive Disease

      In August 2017, the European Society for Cardiology (ESC), in collaboration with the European Society for Vascular Surgery (ESVS), issued updated guidelines on the diagnosis and treatment of peripheral arterial disease (PAD) [41] ; these guidelines were also endorsed by the European Stroke Organisation (ESO).

      Recommendations for revascularization of femoropopliteal occlusive lesions in patients with IC and severe chronic limb ischemia are as follows:

      • Endovascular-first strategy is recommended in short (< 25 cm) lesions (class I recommendation; evidence level C)
      • Primary stent implantation should be considered in short (< 25 cm) lesions (class IIa recommendation; evidence level A)
      • Drug-eluting balloons may be considered in short (< 25 cm) lesions (class IIb recommendation; evidence level A)Drug-eluting stents may be considered for short (< 25 cm) lesions (class IIb recommendation; evidence level B)
      • Drug-eluting balloons may be considered for treatment of in-stent restenosis (class IIb recommendation; evidence level B)
      • In patients not at high risk for surgery, bypass surgery is indicated for long (≥25 cm) SFA lesions when an autologous vein is available and life expectancy is >2 years (class I recommendation; evidence level B)
      • The autologous saphenous vein is the conduit of choice for femoropopliteal bypass (class I recommendation; evidence level A)
      • When above-the-knee bypass is indicated, the use of a prosthetic conduit should be considered in the absence of any autologous saphenous vein (class IIa recommendation; evidence level A)
      • In patients unfit for surgery, endovascular therapy may be considered in long (≥25 cm) femoropopliteal lesions (class IIb recommendation; evidence level C)

      Recommendations for revascularization of infrapopliteal occlusive lesions are as follows:

      • In the case of chronic limb-threatening ischemia, infrapopliteal revascularization is indicated for limb salvage (class I recommendation; evidence level C)
      • For revascularization of infrapopliteal arteries, bypass using the great saphenous vein is indicated (class I recommendation; evidence level A); endovascular therapy should be considered (class IIa recommendation; evidence level B)
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